Incident investigation·December 27, 2024

On 12/27/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of conducting a case management to follow up on several incidents reported by the facility. Incident dated 11/11/2024 indicated a resident, (R1) to have boarded onto a bus while they were on an outing with a 1:1 private caregiver from an outside agency. While under private caregiver's supervision, R1 had left on the bus alone and returned to their private family home. R1 was safely returned to the facility with R1's updated services reflecting a new 1:1 care agency. A second incident occurring 11/12/2024, indicated that a resident, (R2) had been observed by staff walking on foot and leaving the property. Staff attempted but were unable to redirect R2, with R2 continuing out into the public. R2 had voluntarily returned back to the facility by bus within approximately 2 hours with no injuries or changes of condition. Upon review of R2's records, LPA found that R2 medical records have contradicting information on whether R2 can leave unassisted or not. Medical assessment indicates R2 is able to leave the facility unassisted but not dated. LPA is requesting for the facility to update R2 medical assessment and provide a copy. Since the incident, the facility has increase R2, level of care, including 1:1 care companion. The facility was found have responded appropriately to prevent further incidents. A third incident dated 11/10/2024, indicated that a resident, (R3) had been provided a shower by two caregivers. R3 was in a shower chair with a seat harness attached. Caregiver staff reported to management that R3 was observed sliding off the shower chair. Caregiver staff responded by slowly assisting/guiding R3 to the floor for reassessment. R3 had sustained a fracture to the femur but the facility was unable to interview the resident and determine any additional findings for how the fracture occurred. LPA was informed that R3 had utilized a hoyer lift and had a history of general weakness in the knees. The facility responded immediately with R3 sent out on medical emergency and returned the same evening. LPA found that the facility responded appropriately to the incident with no determination on how the injury was sustained. Lastly, LPA and Acting Administrator, Fili Igafo discussed a previous request for a hospice waiver increase. At the time of visit, the facility is within the current hospice waiver capacity and will no longer need an increased hospice waiver or exceptions at this time. No deficiencies cited during today's visit.