Incident investigation·January 19, 2023

Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Wendy Watson. LPA is following up regarding three incidents, the first two involving residents R1 and R2. Facility reported that R1 reported that they were returning to the facility when R2 stood at the entrance to the facility and would not let them pass. R2 indicated that they wanted to assist R1 with their items. R1 declined help but R2 did not move from in front of the door and when R1 requested that R2 leave them alone, R2 laughed. A second incident involving the same residents was reported by the facility and per report, R2 went into R1's apartment without knocking or seeking permission. R1 told R2 to leave and called the police. Following this incident, Administrator consulted with R2's responsible party who agreed to increased supervision but ultimately decided to find different placement for R2. The third incident involves resident, R3 who was being assisted with transfer from their bed by facility staff when they suddenly yelled out and their legs buckled. Staff assisted R3 to the floor. R3 continued to complain of pain so was transported to the hospital where they were diagnosed with a break. LPA reviewed documents including staff training regarding transfers, R3's Care Plan and Physician's Report and spoke with involved caregiver. Per Physician's Report dated 4/17/2020, R3 was diagnosed with a similar injury prior. Per discussion with Administrator, injury is on the same extremity and near the previous break. No deficiencies cited during this inspection.