Incident investigation·March 20, 2025

Licensing Program Analyst (LPA) Sabrina Calzada and Ombudsman arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, and stated the reason for today's inspection. Also present was Robert Godfrey, Regional Director, and Resident Care Coordinator, Ashley Stahl. The facility submitted an incident report (SOC341) to the Department and the Ombudsman's office on March 18, 2025 regarding resident (R1) who was found on the floor in their room on March 16, 2025 (8:00 am). The report states that resident (R2), who was exit-seeking, walked into (R1's) room and pushed (R1) to the ground, causing them to hit their face and sustain a large bruise and bump on the right side of the face. Both residents were taken to the emergency room for evaluation. The (RCC) was asked to provide additional information on the incident and explained that (R1) told her that (R2) pushed (R1) who fell. The RCC stated the fall was unwitnessed and (R1) could have tried to get (R2) out of their room and fell doing so, as they are "very unsteady on their feet". (R2) returned the same day with a diagnosis of a Urinary Tract Infection (UTI) and new medication to take for (7) days. (R1) returned a few hours later with no new orders and is doing fine. Also discussed was how (R1) told their family member March 11, 2025, when picked up for a doctor's appointment, that they had a rash. The family member reported seeing red marks all up (R1's) arms, thighs and back, and a Med-Tech determined the rash to be scabies. (R1) was given a prescribed creme treatment on March 11, 2025 and a second treatment on March 15, 2025. There was not a scraping done to definitively diagnose the skin condition, however, the rash has improved. Staff will complete a skin check later today when (R1) receives a shower. The facility followed proper reporting and procedural protocols in sending both residents out. An outside nurse will be evaluating (R2) soon again regarding their wandering tendencies. There are no deficiencies cited in this report. Exit interview. Copy of report provided to the Administrator.