Incident investigation·May 2, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to several incident reports received in the last few weeks. LPA met with Margarita Guerrero, Business Office Director, initially, and then Mike Talani, Administrator, Lance Ramos, Memory Care Director (MCD), and Nekia Xavier, LVN Health and Wellness Director (HWD). LPA stated the reason for the inspection. The following residents and incident reports were discussed, as follows: On 5/1/24, resident (R1) was found after an unwitnessed fall in her room on 4/23/24. Resident was sent to the emergency room (ER) due to observing a cut on her forehead. Resident was admitted to the hospital and received surgery for a left hip fracture. Resident was also diagnosed with a small brain bleed. Resident was independent in her care needs prior to this fall. HWD confirmed resident recently returned and is doing well. On 4/8/24, resident (R2) fell and sustained a scalp injury. Resident was sent out to the ER immediately and received two staples to her scalp, returning the same day. MCD stated resident is doing well and had the staples removed (10) days later. Resident has a pending order for physical therapy. On 4/14/24, resident (R3) had an unwitnessed fall in his room at 12:40 am, when trying to ambulate to the restroom. Resident would regularly refuse to use his walker, despite many staff, including the in-house physical therapist, encouraging the use of a walker. Prior to this fall, resident had completed a screening with the in-house Physical Therapist and was using the walker more often but was still seen to be ambulating without using one. Resident remains in skilled nursing and is participating in physical therapy until he is stronger to return to the community. On 4/16/24, resident (R4) was found on the floor in her room at 3:30 am and was transported to the ER for further medical evaluation. Resident returned on 4/18/24 with orders for PT, OT, Home Health and antibiotics. Resident will be evaluated if hospice care is appropriate. Resident has swelling in her legs and sometimes tries to get up her own without assistance from staff of a device. Resident's care plan updated. *cont on 809C-1... 809C-1... On 4/18/24, resident (R5) at 9:00 pm, was heard to scream while with care staff (S1) by Med-Tech staff (S2). Staff (S3), went to check on R5 and determined everything was okay. Resident was unable to explain why she screamed, due to a diagnosis of Dementia, but seemed agitated. S1 stated R5 was upset about having to transfer to the toilet. Resident was observed to have a small bruise or discoloration to the wrist and upper arm area on 4/19/24, but this was reported to managers on 4/22/24. The Administrator immediately pulled S1 off of the schedule and placed him on administrative leave; however, the staff member quit before any questions could be asked. The HWD, who is an LVN, assessed resident, and there were no complaints of signs of pain, but the red/yellow discoloration on resident's right forearm was noted. The Administrator stated that staff did not associate resident's scream to the bruising until a few days later, when it was reported. On 4/25/24, staff received training on resident abuse, mandated reported and the importance of timely reporting. The Ombudsman conducted a follow up visit and indicated the facility handled the situation appropriately, and there were no concerns. The police were called and a report number was provided. Additionally, resident's family and doctor were notified. Also discussed today was the non-hospice death, on 5/1/24, for resident (R6). MCD stated resident's death was totally unexpected by staff and the police promptly conducted an investigation and did not find anything concerning. MCD agreed to request a copy of the county death certificate and submit a copy to the Department. Also discussed today was resident's access to the gated/locked pool at the community. The Administrator stated Memory Care residents, or other residents with a diagnosis of Dementia, or MCI, will not have access to the pool. Also, any residents in ALU that are wanting to use the pool must check in with the lobby prior to use. The Administrator confirmed that the pool is always visible during staff rounds and provided a receipt for a new sign (ordered on 4/28/24) to replace the current sign that is faded stating there is "No Lifeguard on Duty", as requested by the insurance company. The Physical Therapist confirmed he has basic life support and CPR certification and he or another PT staff can get lifeguard safety/CPR, to be able to offer water aerobics classes. 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.