Incident investigation·August 28, 2025

Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct a follow up visit regarding a complaint investigation and follow up on incident reports receieved. LPM and LPA met with Marilyn Oterl and explained the purpose of the visit. LPM conducted a tour of the facility and observed: Memory Care area – resident restrooms do not cont ai n soap for handwashing . Intervie w with the designee reported that soap is not allowed in memory care area, technical guidance was provided by LPM on non toxic soap or soap dispensers that should be in each restroom area. Additionally interview with a family member reported that residents are not allo we d electric shavers , numerous resi dents observed unshaven. Guidance provided that resdients are allowed access to electrical razors. Tour of memory care room s revealed sliders and windows inoperable in the common area and in one room toured. Additionally more than 5 rooms observed to have toxins accessible . Breakfast service was done at 8:30 except for those eating in their rooms and included hot cereal, eggs bacon, sausage and coffee cake. LPM also observed juices, oranges and banannas being served. Res idents were seated in the lobby area, activites were to begin at 9 am which was not observed to occur. Guid ance was provided on allowing resdient s to remain in the dining area which was locked and activities such as morning news, talk shows or music to be on while others congregate in the lobby area reducing the number of residents in that area. Ad ditionally it is acceptable to have a TV or music area in the lobby as long as the fire exit is accessible and clear from traffic in case of emergency. Engageing res idents throughout the memory care area should allow for this and engage the residents. An additional tour was conducted after lunch, no activites were being offered and the dining room was locked again. Additional guidance provided. First hall in MC is malodorous. Temperature comfortable although portable units located throughout building. Linen available in washroom. Cont Assisted Living was toured residents appeared content. Resident rooms were inspected for clean linen, cleanlieness and odor as well as operable windows and sliders. During the inspection two rooms were observed to be dirty, inc. used briefs in garbage, excess garbage and clutter and dirty floors. Two residents reported that housekeeping is provided one time a week. Common areas were observed to be cle an. House Keeping room was open and assessable to clients. Common door on hall to the exterior was locked from inside and not accessible. This should remain unlocked during busineess hours. One room was toured with an excess of 10 O2 canisters unsecured documentation was reviewed, on two occ asions the facility has reached out to the company to provide holders, no other means of securing for safety have been made. LPM interviewed the chef regarding meal substitutions. A request was made to review consultation notes from the facilities registered dietician. The chef confirmed that they have not met the dietician and reports were not available for review. Vegartariens are provided substitutions but there is no record of what is being served and if it meets requirements. A review of incident reports occurred for 11 residents. Documentation was requested via email and included hospital discharge (DC) documentation, Medication administration records (MARS) and care plans(CP) for review prior to todays visit. R1 had 2 unwitnessed falls between the months of 05/2025 and 07/2025, one of which resulted in a fracture. The hospital documentation was reviewed as well as the CP during this time period. Although the CPs were updated the change in condition is not noted and pain management is not addressed. Additional follow up is needed and R1s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. R2 had 5 unwitnessed falls in a period of less than 3 months. A review of medical records was conducted, CPs are documented as being updated, however there is no update to the problems or interventions thus it does not appear that interventions were not put in place to address residents’ risk of falls. No fall risk is identified on the CP. Additionally, interventions are generalized and are not personalized ie staff to understand resident’s activity preference. cont. R3 had 3 incident report, 2 of which resulted from the resident themselves calling 911 for assistance due to pain and the third resulted in a higher level of care being needed. A review of the CPs provided and dated 3/13/25, 5/03/25 and most recently 5/28/25. 05/28/25 CP documents that a third party provider will provide and manage skin care. No showering or toileting assistance is provided on the 5/8/25 CP. Home Health documentation shows the resident was being seen by homehealth 2xwk for woundcare on four separate areas. Additionally, no interventions or frequency of homehealth is documented. The condition worsened requiring a higher level of care. The CP although updated did not document the change in condition including new or worsening wounds, facility oversite of care being provided and pain management. Additional follow up is needed and R3s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. R4 was hospitalized on 2 separate occasions in the past 6months. A review of medical records was conducted, CPs have been updated. Interventions are generalized and are not personalized ie there is a third party vendor in place to assist with management of skin care/wounds, however no description of the wound(s) locations, status, treatment or measurable goals are noted on the resident’s CP. R5 additional follow up is needed. The RO has requested the licensee to collect and provide the Death Certificate by 10/01/25. Additionally, statements on the CP are not personalized ie “staff to provide diet as indicated on the dr order” (resident is on a texture modified diet which is not identified in the treatment/intervention area of the CP). R6 had 4 falls from 5/2025 to 08/2025, 3 of which occurred during the same month. A review of the CPs was conducted which revealed that although the CP is documented as being updated, the generalized intervention remains, “staff will provide oversight and complete interventions to help reduce residents fall risk”. Interventions are not documented and the CP is not updated to address the fall risk. Additionally a change of condition CP was provided and dated 08/03/2025 which is incomplete and lacks problem statements and interventions. cont. R7 was sent to the ER due to agitation a change of medication was noted and 2 subsequent falls were reported. A review of the CP documents updates were made, however it is unclear what changes were made. Interventions do not include behavior modifications or monitoring for side effects of new medications which may have attributed to falls. Additionally, a review of R7s MARS for the months of June 2025 thru Aug 2025 was conducted and revealed on 6/26/25 am meds were not documented as being provided. Additionally an inhaler was not provided during the month of June, July or August. According to documentation provided by the facility and dated 03/15/25 the resdient had a high co pay therefore medications were not ordered. The facility was reminded that the facility should have paid for the medications and billed the resident or communicated with the physician to seek an alternative, In addition, medications were refused on the following dates, 07/11, 13, 16, 17, 17, 20, 25. No IR received for refused of missed medications, however communication was provided to the collaborative agency. R8 has 4 unwitnessed falls from May 2025 to Aug 2025, one of which resulted in a fracture. A review of CPs, hosprpital DC documents, Hospice Admissions and Hospice Care Plan and MARS was conducted. Additional review is needed, additional documentation has been requested and received. R9 had 3 falls from June to July 2025 one of which resulted in a fracture. A review of the CPs during that time period was conducted as well as hospital DC documents. Additional follow up is needed and R9s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. R10 over a 1 month period had 5 ER visits and is currently hospitalized. A review of the CPs and Mars for the same period was conducted. Additional follow up is needed. Additional follow up is needed and R9s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. cont. R11 had 6 unwitnessed falls over a 2 month period. A review of the DC documents, CPs and MARs was conducted. Although CP documents fall risk and to ensure all staff are aware of fall risk, no specific interventions are noted just that they will be implemented. This is a generalized statement not specific to the care of this resident. On 06/19/25 the department was notified of a resident on resident altercation via an incident report. The incident did result in a resident being sent to the ER no significant injury wass noted, however one resident does have a history of agitation. Any altercation should be submitted via a SOC341 and cross reported to all parties. Technical Assistance is provided. An exit interview was conducted with designee Marilyn Otero, citations were issued and are attached on the D page. Appeal rights were provided.