Incident investigation·March 6, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Nekia Xavier, LVN Health and Wellness Director, Mike Talani, Administrator, and Lance Ramos, Memory Care Director. LPA stated the reason for the inspection was to obtain additional information on several incident reports recently submitted to the Department. (R1) had an unwitnessed fall on 3/2/24 in her room and was sent to the hospital due to complaints of pain in her right leg/hip. Resident remained in the hospital until on/around 3/6/24 when she was transferred to a skilled nursing facility for physical therapy. Staff stated resident was not a fall risk and this was a first fall. Prior to resident returning, an updated care plan will be completed. (R2) was sent to the emergency room on 2/23/24 due to showing flu type symptoms. Resident had a pacemaker installed and was sent to a skilled nursing for rehab services following surgery. Resident will be reassessed prior to returning to the community and the care plan will be updated upon return. (R3) had a new medication order approved before the medications arrived. Staff inadvertently noted that the resident had received the medication when the resident had not. A note was later made in resident's file that the medication was not received, as indicated, and an in-service training was completed on correct medication documentation. This same medication was then discontinued 1-2 days later. (R4) was sent to the emergency room on 2/20/24 due to a wound on resident's right lower leg to appear to be worsening. Resident was treated for cellulitis and returned the same day to the community. Resident was receiving home health services and wound care treatment was added following the hospital stay. Resident was receiving assistance with showers prior to going to the hospital. Resident is being considered for hospice care due to other diagnoses. **cont on 809C 809C- (R5) had an unwitnessed fall on 2/21/24 in the dining room, sustaining some facial abrasions. Resident was sent to the emergency room and given antibiotics, returning the same day. Staff confirmed that resident was diagnosed with a UTI and an updated incident report was provided to LPA during today's inspection to include the hospital diagnosis. (R6) unexpectedly passed at the community on 3/4/24 and was not under hospice care. Facility staff stated there were no signs or symptoms indicating resident was going to pass soon, and resident was awake and alert with a Med-Tech a couple of hours before. Resident was also observed to be very active the day before. Resident had a diagnosis of acute respiratory failure, COPD and Hypertension and used oxygen on a regular basis and she was found using the oxygen concentrator when found non-responsive. The Sheriff came out and completed a report upon being notified of resident's passing. The Administrator agreed to request a copy of the county death certificate from resident's family and provide to the Department since resident was not under hospice care at the time of her passing. It appears the facility took appropriate action in sending residents out for emergency medical care in each situation and provided staff training when a medication documentation error was made. There are no deficiencies cited in this report. Exit interview. Copy of report provided to the Administrator.