Incident investigation·January 5, 2022

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection as a follow up to (3) incident reports that were recently received. LPA met with Kathleen Gilby, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA was advised of a positive staff case during today's inspection from 12/30-/2021. Staff last worked 12/27/202 and an incident report was sent to the Department on 12/31/2021. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA was screened upon entering the facility. The following incidents were discussed with Memory Care Director (MCD), Megan Leone, and also with Administrator, Kathleen Gilbey, with additional information obtained, as follows: Resident (R1) sustained a fall on 12/30/2021, fracturing her hip, and was sent out for emergency services immediately following the incident and returned on 1/4/2022, under hospice care. MCD stated that R1 believed that her walker was no longer hers and wouldn't use it regularly with ambulating, which caused her to fall in the dining room. Resident (R2) was administered a second dose of the evening dose of Nitrofurantoin to treat a urinary tract infection on 12/21/2021. Resident's physician was notified via fax by the facility and resident is doing well. Resident (R3) displayed combative behaviors with other residents in Memory Care on/around November 2021 and on several other occasions in the months prior. MCD stated that R3 was unable to communicate her needs and was placed on hospice in early December 2021. Resident was receiving medication for pain and her physician was advised of resident's behaviors. Resident passed on 12/26/2021 and was provided with a copy of the death report (LIC624A) that was faxed to the Department on 12/27.2021. It appears the facility took appropriate action following each incident. Discussed more complete documentation needed on incident reports submitted. There were no deficiencies found. Exit interview. Copy of report provided to Administrator.