Incident investigation·June 16, 2022

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the recent receipt of several incident reports (LIC624) for multiple residents. LPA met with Kimberly Hagen, Administrator, Sharika Montenegro, Resident Services Coordinator, and Ingrid Weber, Memory Care Director. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and confirmed the number of positive cases currently at the facility. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. The following incidents were discussed for each resident as follows: Resident (R1) is an ILU resident who was sent out on 6/9/22 (4:35 pm) following the discovery of skin breakdown on lower shin and buttocks. Resident fell twice on 6/8/22, in the morning and evening- both falls were related to slipping from the wheelchair. On 6/9/22, (7:45 am) resident slipped off her bed. Resident refused medical transport following each fall but was sent out later that day. Resident is currently rehabilitating at a skilled nursing facility and will be re-valuated upon return for Assisted Living. Resident (R2) fell on 6/9/22 at 4:50 pm when trying to get up from the toilet. Resident was sent out due to complaints of right hip pain. Resident returned from the ER the same day with no injuries or changes in medications. Resident reminded to push pendant if needs help. Remains at level 0. cont on 812C(1).. Resident (R3) fell on 6/8/22 at 2:40 pm after slipping from the recliner chair. Resident was sent out to the ER due to high blood pressure and returned the same day. Resident was also recovering from Covid and has been placed on hospice as of 6/15/22. Resident (R4) resides in ALU and was sent out on 6/9/22 for an evaluation due to erratic behavior observed. Resident has a diagnosis of Bi-Polar and has started to decline. Resident was given a change in medications and the family has been staying with resident more. Additionally, a private companion has been hired to stay with resident 2 hours during the evening time. Administrator stated she will continue to work with the family and staff will continue to redirect resident, pending the effectiveness of the recent medication changes. There are no deficiencies cited during today's inspection. Exit interview. Copy of report provided to Administrator.