Incident investigation·April 9, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on (2) incident reports recently submitted to the Department. LPA met with Henry Cole, Administrator, and stated the reason for the inspection. LPA and Administrator discussed the following: Resident (R1) was sent to the ER on 4/2/24 when care staff were not able to remove the contact from resident's right eye. The contact was removed and resident returned the same day with Polymyxin B – 1 drops to be administered in the affected eye 3 times a day for 7 days. A new eye contact ordered. Facility staff has tried to encourage him to use his glasses but he prefers contacts. This is an isolated incident. Resident (R2) was found to be intoxicated, in his room, on 4/4/24 and sent to the emergency room. Resident has since transferred to a skilled nursing facility for physical therapy and is expected to return in (2) weeks. Administrator stated he has discussed the situation with resident's family members previously and in recent weeks and will discuss obtaining an order from the doctor for a limited daily amount of alcohol. The Administrator stated (R2) is alert and oriented and independent with purchasing alcohol. LPA reviewed resident's physician's report (7/28/23) where it's noted resident consumes alcohol and has a related medical condition. Resident was sent to the ER in February 2024 for a similar incident. Administrator will reach out again to resident's family member(s) to schedule a meeting to discuss obtaining an order for a daily alcohol limit and keep the Department updated. Also discussed was how the incident report should be completed as best possible and submitted to the Department within (7) days of the incident. There are no citations issued in today's report. Exit interview. Copy of report provided to the Administrator.