Incident investigation·March 26, 2024

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit. The facility self reported an incident involving Resident #1 (R1). The report indicated on 03/06/24, R1 fell and sustained a laceration to their head. The facility acted appropriately with medical care. At the hospital, R1 received sutures to their head along with a diagnosis of Salmonella. According to the Executive Director (ED) their Infection Prevention Specialist has been working with the Department of Public Health regarding contact tracing. The Infection Prevention Specialist stated there were a total of four (4) resident cases. However, some were isolated incidents based off uncleanliness. All residents are doing well and were prescribed antibiotics. Today, LPA observed the walk-in fridge and freezer at the facility, it was clean and maintained. The facility has one main kitchen that serves food to all the buildings. Therefore, it does not appear to be an issue with food contamination. On 03/22/24 the Infection Prevention Specialist conducted an In-Service Training on Infection Control on 03/22/24, proof of training was collected. The Infection Prevention Specialist stated she will continue to communicate with Department of Public Health until the case is closed by Public Health. The facility also self reported an incident involving Resident #2 (R2). R2 eloped from the facility on 03/15/24. The ED explained R2 was fairly new the community as of 02/15/24. R2's Physician's Report dated 01/17/24, indicated R2 cannot leave the facility unassisted. R2 was found by a citizen that called 911 for R2. R2 was transported to the hospital for evaluation, with no injuries. The ED stated they searched for the resident, notified R2's responsible party, and notified local law enforcement. The facility followed their Absentee Notification Plan. R2 returned to the facility and was provided with a wander guard bracelet and relocated from the Assisted Living portion of the facility to their secured Memory Care Unit. No deficiencies were observed today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Resident #2]