Incident investigation·June 12, 2025

On 06/12/25, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct a case management visit and met with Administrator, Darrell Price and explained the purpose of today's visit. Case management visit was conducted regarding following incidents reports reported by facility for residents: Regarding resident, R1- Incident report (LIC624) submitted by facility indicated that resident, R1 was sent to hospital on 05/16/25 as R1 was having suicidal thoughts. It was learnt from record review that R1 returned from hospital on same day without any changes in their medications were doing fine as of today with no further incident(s). Regarding resident, R2- Incident report (LIC624) submitted by facility indicated that resident, R2 was sent to hospital on 05/14/25 around 1130am, as staff noticed R2 with open wound on scalp bleeding, not getting any better with a foul odor. Record review that R1 returned from hospital on 05/16/25 with new treatment order for wound management and with home health orders. Regarding resident, R3- Incident report (LIC624) submitted by facility indicated that resident, R3 attempted to leave facility premises on 05/26/25 around 08:50AM without staff’s assistance. Report indicated that R3 was sitting in the patio area and staff saw R3 going on sidewalk of the facility without staff’s presence. Staff brought back R3 to the facility without any injuries. It was learnt that R3 was doing fine as of today with no further incident(s). ....report continued.... ***Report continued from 809.... Regarding resident, R4- During complaint investigation of 59-AS-20250502153659, department noticed during record review that R4 got admitted to facility on 04/01/25 and pre-admission appraisal was done by facility on 03/26/25 but facility could not verified if R4 and/or responsible party was involved during the draft of this document as there were no signatures by R4 and/or responsible party on pre-admission appraisal as required per regulations. Regarding resident, R5- Incident report (LIC624) submitted by facility indicated that resident, R1 was sent to hospital on 06/10/25 after R5 sustained a fall at the facility around 1:00AM. LIC624 reflected that R5 did not complain any pain after the fall and refused to go to hospital but complained later around 06:30AM regarding pain in the back and been sent out to hospital to sought medical care. It was learnt from record review that R1 returned from hospital on same day with diagnosis of spinal fracture and with order of back brace to be used while walking. Files were reviewed for above residents, and it appeared that appropriate actions were taken regarding these incidents by facility. Facility notified all required parties regarding these incidents. No deficiencies were cited per Title 22 Regulations however Technical Assistance(s) have been issued. Exit interview was conducted and a copy of the report was provided.