Incident investigation·June 11, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to obtain additional information for (2) incident reports recently submitted to the Department. LPA met with Henry Cole, Administrator and stated the reason for the inspection. The following residents and incidents were discussed: On 5/14/24, resident (R1), who was independent with her medications, stated she didn't want to live anymore and was going to take the vitamins stored in her room. Staff immediately removed the vitamins and contacted the Police, resident's family and hospice staff. The police arrived to interview (R1) and a 1:1 caregiver was assigned until a hospice nurse and social worker were able to interview resident. The Administrator stated (R1) was falling a lot and is now stabilized. On 6/3/24, resident (R2) lost her balance and fell while walking in the hallways, around 3:15 pm. Resident injured her right elbow and forehead, causing bleeding, and was sent to the emergency room. Resident was admitted and returned to the community later on 6/3/24 (9:40 pm). No follow up appointments were scheduled or any new medications prescribed. (R2) is back in the community and is doing fine. The facility responded immediately and appropriately to each resident and submitted incident reports (LIC624) to the Department timely. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.