Incident investigation·July 13, 2021

At 1:25 PM Licensing Program Analyst (LPA) Angela Elliott and LPA Shannan Hansen arrived unannounced to conduct case management visits for a series of incidents at the facility. LPAs met with Dorene Warchut Resident Services Coordinator. On 6/7/2021 R1 was discovered on the floor of their dining room. 911 was called and R1 was assessed at Queen of the Valley Hospital and diagnosed with a fractured left should and right knee. Currently R1 is at the Skilled Nursing portion of the facility for physical therapy and occupational therapy and has been added to the falls committee. It is expected they will return to the facility after treatment. On 6/30/2021 R2 was having episodes of spitting up phlegm and yellow substance. R2 was also complaining of chest pain, was sent out to Queen of the Valley Hospital and returned to facility on 7/1/2021. On 7/2/2021 R2 asked for staff assistance to the bathroom three times. R2 appeared to be having a seizure at one point was having chest pain and indicated they felt weak. R2 was sent to Queen of the Valley and was diagnosed with Norovirus. R2 came back to the facility on the 7/4/2021 and was isolated. Facility ceased communal dining and activities during this time and they were restarted on 7/7/2021. There have been no further cases diagnosed at the facility. On 7/8/2021 R3 was having difficulty breathing, 911 was called and R3 was diagnosed with Dyspnea and Apneic episode. X-ray noted some opacities possibly due to aspiration. R3 has been assessed with speech evaluations to determine the appropriate diet. R3 and family does not consent to recommended texture of diet. Treatment meeting was recently held and it was determined to leave current diet in place with acknowledged risks. Current diet is regular. LPAs requested documentation. No citations issued during today's visit.