Incident investigation·August 31, 2023

At approximately 1:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Angie Boucher Turin. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1/Incident Report 2/Incident Report 3: CCL received 3 incident reports involving Resident 1 (R1). Incident Report 1 was received on 08/16/2023 which reported that on 08/15/2023, R1 was observed to have a change in condition. Facility notified Emergency Personnel and R1 was taken to the hospital where they were diagnosed with C-Diff. Incident Report 2 was received by CCL on 08/18/2023 which detailed an update regarding R1. Report states that on 08/17/2023, R1 was discharged from the hospital and transported back to the Facility against Facility's recommendation and State Regulations. R1 was returned to the facility late that evening. Facility ensured that R1 was quarantined upon arrival and that Universal PPE Precautions were in place. Incident Report 3 was received on CCL on 08/21/2023 which detailed an update regarding R1. Report states that R1 was admitted to a Skilled Nursing Facility on 08/18/2023 until they are no longer infectious with C-Diff. Per conversation with Executive Director, Facility informed Hospital that R1 cannot be accepted back to the facility if they are still considered contagious. Review of R1's discharge paperwork did not indicate if R1 was still infectious upon their return to the facility on 08/17/2023. Facility determined that it would be best to admit R1 to a Skilled Nursing Facility until they have recovered from C-Diff. R1 was admitted to a Skilled Nursing Facility on 08/18/2023. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.