Incident investigation·April 8, 2022

On 4-8-22 at 12:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 4-3-22. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPA’s visit and gave permission for Jenna to accommodate LPA and sign in her absence. LPA interviewed Administrator, Resident1 (R1) and R2 and reviewed incident report and resident records for R1 and R2. Based on interviews and record reviews it was determined that on 4-3-22, R1 and R2 were noted by staff to engage in an action in facility’s memory care unit which required facility to report. Based on interviews, it was determined that this action was mutual and without violation of resident rights. Record review and interview has determined that increase focus of supervision and updated plans of care are in place for R1 and R2 to address behaviors and safety measures. Facility reported incident to licensing department, ombudsman, and local law enforcement per regulations. LPA conducted facility observation of memory care unit at 12:50pm. Unit alarm doors are functioning and staffing levels were appropriate during observation. All toxins and other dangerous materials are not accessible to residents in care. Temperature of unit was between 68*F and 85*F. Fire extinguishers were fully charged. Unit was clean and sanitary with no foul odors noted. No deficiencies noted. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.