Incident investigation·September 21, 2021

Licensing Program Analyst (LPA) Angela Elliott arrived unannounced to conduct a case management related to incidents. LPA met with Viridiana (Viri) Agapoff, Manager. The first incident occurred on 9/2/2021. R1 went out their side door and out into the street due to hearing noises outside. The alarm on the door was activated when they opened the door. S1 kept R1 in sight the entire time. S1 was able to re-direct R1 back into their room. Per Viri care plan was not updated as a result of this incident. R1 is monitored constantly and there have been no similar incidents. The second incident occurred on 9/20/2021. R1 was discovered on the floor of their bedroom. R1 indicated that they were trying to get to their bed from their wheelchair but slipped. Fire Department assisted with getting R1 off the floor, no injuries sustained. Incident report reflects R1 said it was S2's fault that it happened. Per incident report S2 was in their office at the time. Per Viri care plan was not updated as a result of this incident, and resident is doing well. No citations for deficiencies issued. LPA also dropped off PPE.