Incident investigation·October 13, 2021

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of (2) incident reports. LPA met with Donald Stamets, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community via Accu-Shield system. . LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA, Administrator and Dulce Carreon, Health Services Director, discussed recent incident reports received for resident (R1) and for resident (R2), as follows, and obtained copies of physician's reports and hospital discharge papers: Resident (R1) fell on 10/2/2021 (4:05 am) and was sent out for medical attention and returned to the facility the same day with antibiotics for a urinary tract infection. R1 was moved to Memory Care unit on/around 10/2/2021 since resident was observed to be wandering more and an updated care plan was written. Resident fell again on 10/9/2021 (3:35 am) as resident is accustomed to waking up and wandering during part of the night and was also acclimating to the new living unit. On both falls, resident was wearing mule clogs and is now wearing sneakers better support his feet . There were no changes in resident's medications following each visit to the emergency room. Resident is doing well currently. Resident (R2) fell on 9/29/2021 and on 10/4/2021 and was using her walker during each fall. Resident was sent out to the emergency room after each fall and returned on 10/1/2021 and on 10/4/2021, respectively, with no changes in medications. Resident was given general fall prevention resources at discharge on 10/4/2021. Resident was a respite resident and has since relocated to the Aegis community she was planning to move to on/around August 2021 but was unable to due to Covid-19. It appears the falls could not have been prevented. There are no deficiencies being issued on this report. Exit interview. Copy of report provided to Administrator.