Oakmont of Carmichael

Allegation investigated: Resident sustained injuries from a fall while in care due to lack of supervision.

On 4/12/23, Licensing Program Analyst (LPA) Kevin Mknelly arrived, met with the Executive Director, and explained the reason for the visit. The purpose of this inspection was to investigate the allegations sited above. Licensing Program Analyst (LPA) Kevin Mknelly received copies of the following: the internal incident report of a fall by R1 on 12/18/22 (recorded previously as 12/19/22- 12/18/23 is the correct date), Hospice record of care provided for the injuries from that fall, name of the caregiver(s) who attended to R1 or witnessed the incident (if no longer employed, contact information on record) if still employed, April 2023 work schedules. LPA observed R1 receiving assistance while dining. LPA interviewed 4 staff and a hospice RN. Hospice Visit notes for R1, on 12/18/22 note "...new laceration... roughly 1 cm long... wound started to scab... no signs of bleeding or infection... cleaned... ATB ointment applied..." - Report continued Unsubstantiated Hospice records showed that the wheelchair used by R1 on 12/18/23 was newly provided and was delivered without the proper cushion for positioning. Interviews found that 4 staff were present conducting a shift change briefing and that R1 was seated in their wheelchair approximately ten(10) feet away, partially obscured by a post, at the time of R1's fall . According to staff statements, R1 had not made any typical vocalizations of distress or discomfort prior to staff hearing a fall had occurred. When the briefing took place, statements indicate R1 to be seated nearby quietly and not in need of assistance. Evidence suggests that R1 had moved unexpectedly and without warning resulting in an accidental fall. R1 was not requiring 1:1 staffing. Staff present responded immediately after the fall to provide first aid. Hospice was notified promptly and R1 was seen by hospice 12/18/23. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator.the state’s words, verbatim · CDSS document, Apr 12, 2023 · control 25-AS-20221227151037

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/7/23 to conduct a Continued Annual Inspection. LPAs met with Executive Director and explained the purpose of the visit. LPA completed Resident file reviews during this visit. Inspection found three(3) of six(6 residents with physician's reports out of date. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted and copy of report and appeal rights left at the facility.the state’s words, verbatim · CDSS document, Apr 7, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Kevin Mknelly Ivan Avila arrived at the facility unannounced on 4/6/23 to conduct a Annual Inspection. LPAs met with Executive Director and explained the purpose of the visit. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 9 resident bedrooms, bathroom, kitchen, laundry room, and exterior. In the areas toured no immediate health, safety, or personal rights violations were observed. Resident care needs appear to be met. LPAs conducted staff file reviews and were unable to complete Resident file reviews during this visit. LPA Mknelly will return to complete the inspection. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Apr 6, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection related to a deficiency discovered during complaint investigation #25-AS-20220519170123. LPA met with Administrator, Kathleen Gilbey, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask During the investigation, Medication Administration Records (MAR) were reviewed for months April- September 2022 for resident (R1), the subject of the complaint investigation. On 10/11/22, LPA also reviewed (3) staff files and training records and interviewed staff (S1). Staff (S1) stated to LPA on 10/11/22 that they have completed (8) hours of initial medication training but had not completed medication shadowing hours as required. MAR for July 2022 shows S1 administered medications to R1 on 7/2/22 and on 7/10/22. Staff training records show that staff (S2) had completed (8) hours of initial medication training on 7/10/2022 but had also not completed the required initial (16) hours of medication shadowing. MAR for July 2022 shows S2 administered medications several times from 7/20/22- 7/30/22, in August 2022 and September 2022 for R1. Records review shows staff (S3) had not completed (8) hours of continuing in-service medication training required within the last 12 months. MAR records show S3 consistently administered medications to R1 from April 2022- August 2022. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 809D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 8, 2022

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(3) · Plan of correction due date: Jan 16, 2023

§1569.69 Employees assisting residents with self-administration of medication; training requirements. (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment. This requirement is not met as evidenced by: Based on record review and interview conducted, the Licensee did not ensure that staff (S1 and S2) had the required initial shadow training prior to administering medications, posing a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 8, 2022

Plan of correction: Licensee/Administrator agree to ensure all staff administering medication are current in their initial medication training. Documentation of completed required training to be sent to the Department by 12/22/22.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69(b) · Plan of correction due date: Jan 16, 2023

§1569.69 Employees assisting residents with self-administration of medication; training requirements: (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by: Based on record review, the Licensee did not ensure that staff (S3)had completed the required ongoing medication training within the last 12 months from when the review was conducted on 10/11/22, posing a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 8, 2022

Plan of correction: Licensee/Administrator agree to ensure all staff administering medication are current in their ongoing medication training. Documentation of completed required training to be sent to the Department by 12/22/22.

Allegation investigated: Resident did not receive a shower chair for a long period of time. Resident developed a rash while in care. Resident's hygiene needs are not being met.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint received by the Department on 5/19/2022. LPA met with Kathleen Gilbey, Administrator, and explained purpose of inspection. LPA later met with Ron Cheek, Memory Care Director, who assisted in providing additional documentation as requested, pertaining to resident (R1). Prior to initiating today's inspection, LPA completed required COVID-19 screening protocols and was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and wore a surgical mask. During the investigation, LPA interviewed Administrator, (2) prior Memory Care Directors, current Memory Care Director, (6) Med-Tech/Caregiver staff, Activity Coordinator, Ombudsman and resident (R1). LPA was unable to conduct (2) additional staff interviews. LPA reviewed documentation including, but not limited to: physician’s report, Care Plan (9/5/22) Medication Administration Record from April -September 2022, resident charting notes, multiple fax communications to physician, physician’s orders, home health records and hospital discharge papers. The results of the investigation are as follows: cont on 9099C(1).. Substantiated 9099C(1)..Resident (R1) moved into the Memory Care Unit of the facility on/around August 10, 2021 from a skilled nursing facility. Resident’s physician’s report, dated 7/29/2021, indicates resident has a diagnosis of Dementia, Type 2 Diabetes, has auditory impairment, is able to participate in bathing and needs assistance with toileting. Allegation: Resident did not receive a shower chair for a long period of time. Complaint states that resident did not receive a shower chair for months. Staff interviews revealed that resident had a shower chair upon moving into the community in August 2021 and that the chair actually belonged to resident's roommate but she was able to use it. Fax communication to resident’s physician, on 9/26/2021, notes resident had a “guided fall” while being assisted in the shower as resident was sliding down in the chair when she began screaming and kicking staff members. Staff interviews also indicated that when resident moved to another room on/around March 2022, she did not have a shower chair to use for a while and so staff had to try and shower resident while she was in her wheelchair. Another staff stated that she saw a chair in resident's personal shower at one point but then it disappeared, so she checked in the laundry room and the chair was not there. A third staff stated on 5/24/22 that staff was "still trying to get the doctor to fax an order- she is not using one that I know of". Physician Fax reports show a request for an order was made for a shower chair on 4/19/2022 and 4/27/2022. A fourth staff stated resident was "always scared to stand up" and she had a chair and "we used her wheelchair " also and sometimes it took (2) of us to shower her. Staff stated resident got a shower chair in September 2022. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- Allegation: Resident developed a rash while in care. Complaint alleges client has rashes on her breast and stomach and smells very bad. All staff interviewed indicated that resident was challenging to give a shower to and would often resist staff trying to bathe her. Several staff stated that resident would go weeks without a shower due to not liking the water with one staff stating "she never got showered" and "constantly had a rash under her breast". cont on 9099C(2).. 9099A-C(1)...Resident care notes from 8/13/2021 indicate resident was sent out to the hospital for further evaluation of her chronic back pain and sacral ulcer. Discharge papers show resident returned to the facility the same day with pain medications and information about preventing pressure injuries. Home health records show on 8/14/2021 resident was treated for a Stage 2 pressure ulcer on mid upper buttocks and complaints of mild pain and was seen again on 8/21/2021 for continued wound care to Stage 2 and for a Stage 1 on the right heel. Resident received a prescription for Calmoseptine ointment on 8/24/2021 to be applied twice daily until healed, was seen again on 8/27/2021 to assess and instruct regarding existing (2) wounds and was discharged on 9/3/2021 with wound care instructions of “frequent position changes, continue applying moisture barrier cream with incontinence skin care”, noting resident had a “Stage 2 inner gluteal pink skin, not open with flaky skin”. Physician's fax report sent on 4/15/22 by a prior MCD to resident's primary care physician at the time, states, in part staff has noticed an increase in redness and some small open areas forming.. we continue to use the calmoseptine in those areas but little to no effect" and resident is in pain and agitated.. Physician's response received on 4/18/22 states resident has an order for Norco already and to add Tylenol twice daily. An antibiotic treatment of 14 days was prescribed on 4/20/22. MAR documentation shows Amox Clav 875-125 mg tablets were given for 14 days, starting on 4/21/22 through 5/4/22 and Clotrimazole-Betamethasone creme was applied twice daily, for 20 days starting on 4/27/22 in the evening. Physician's fax report sent on 5/9/22 describes resident to have (2) open sores in her groin area and (2) that are bleeding and physician's fax report sent on 5/19/22 reports resident has "redness, bumps and peeling under both breasts" and requests another order for Clotrimazole-Bethamethsone cream as the 20 days has finished. Resident was sent to the emergency room on 5/20/22 and received a prescription for Nystatin topical powder and Keflex capsule. MAR shows Keflex was administered 3 times daily for 7 days, as prescribed, effective 5/21/22; however, resident did not receive the prescribed cream on 5/17/22 due to needing a refill. A new order was written on 5/24/22 but was not given on the evening of 5/30/22 and on 5/31/22 due to waiting for a medication delivery. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED. cont on 9099A(C2).. 9099AC(2).. Allegation: Staff did not seek medical attention for resident. Complaint alleges that a Med-Tech falsely documented that client has already seen a doctor regarding the issue of rash from head to toe. LPA reviewed multiple Physician's Fax Reports dated 4/15/22, 4/19/22, 4/27/22, 5/4/22, 5/6/22, 5/9/22 noting different facility staff reported to resident's physician that resident had pain, redness and swelling in groin/buttocks to be worsening. some areas appear to be pealing, bumps have appeared on her arms and body, complaining of lower abdomen pain during urination. Many staff stated that resident's physician was difficult to get in contact with as well as resident's conservator. Staff stated that when resident's physician did respond, she indicated she needed to see resident in person. Fax physician report dated 4/27/22, reads "Please make appointment to see PA (Physician's Assistant)". Resident was sent to the Emergency Department on 4/19/22 and 5/19/22 and was not seen by her primary care physician at the time. Resident's conservator authorized the facility's concierge physician to begin seeing resident on/around June 2022. Documentation reviewed for June 2022 and forward show the facility received a timely response and resident was seen by the physician when reaching out. It was not able to be determined by documentation if a Med-Tech falsely documented that resident had seen her physician to treat the rash. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. 9099C(2).. Physician’s fax report dated 12/25/2021 notes while toileting resident, staff “noticed a large hand sized patch of blotchy red skin under her left breast… and a dime sized bump” not previously seen before. A prior MCD stated “the rash was "on her arms and thighs", and "the rash did improve with bathing". The prior MCD commented it is "definitely a fungal rash" and also “she had a yeast under her breast”. Another MCD stated that resident resident enjoyed the jacuzzi and would sometimes cooperate better with staff than when trying to bathe her in the shower. A caregiver staff confirmed on 5/24/22 that resident did go to the ER "because of the rash" as the the NOC shift Med-Tech said resident was complaining off pain and the rash was "itchy and burning". LPA reviewed note from resident's physician, written on 6/17/22 following visit on 6/8/22, which says “perineal rash is likely a fungal dermatitis due to poor hygiene (wears Depends) and her poorly controlled DM (Diabetes Mellitus)". Physician's report, dated 9/8/22, says resident has dermatitis associated to incontinence. Current MCD stated on 9/22/22 resident's rash " is better and staff is still using creme". MAR documentation shows Menthol-Zinc Oxide ointment, or Calmosepine ointment, was prescribed on 12/14/2021 and was administered starting on 9/8/22, for the month of September, when resident returned to the facility. A prior MCD indicated that resident would refuse showers regularly and she "finally got her to take one" and resident "would scream and scream" in the shower when the water started. Staff interviews confirmed that if a resident refuses on a regular basis, not all staff will try and redirect the resident to be able to give the shower. LPA finds this allegation to be SUBSTANTIATED. Allegation: Resident's hygiene needs are not being met. Complaint alleges client has only been showered 3 times in the past 4 months. One staff stated resident was not showered the entire month of Sept and went 6 weeks without shower. Another staff stated "the challenge is she resists, she needs a 2-person assist and she would scream "don't touch me". A third staff stated she and another staff gave resident a shower recently and it was difficult", stating "it's extremely hard to care for (R1)" and she is "definitely a 2-person assist" for the last year. A fourth staff stated "she never really wanted to shower" and she would refuse and went weeks without receiving a shower" and "some of the caregivers on the NOC shift gave her a shower because they couldn't stand seeing her unshowered for so long. Several staff stated they would report to the lead- Med-Tech, verbally that resident was not showered and nothing was done. 9099c-(3) 9099C(3).. An additional staff confirmed on 5/24/22 that "resident does not like showers and throws herself on the floor", stating that she "believes that no matter the time of day or which caregiver, (R1) won't cooperate with showers. Last week we were able to give her a shower on the NOC shift. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulation, Title 22, Division 6, Chapter 8, the following (2) deficiencies are cited on the 9099D pages. Exit interview. Copy of report provided with appeal rights.the state’s words, verbatim · CDSS document, Oct 11, 2022 · control 25-AS-20220519170123

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 13, 2022

87464 Basic Services. (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that resident (R1) received scheduled showers, twice weekly, on a consistent basis, from May 2022- September 2022, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2022

Plan of correction: Licensee/Administrator already conducted training with "pm" and "NOC"caregiver staff. Resident is now receiving daily showers, Mon-Fri, effective 3 weeks ago, and has a shower chair and is cooperating better. Time of shower has changed and resident is doing better. MCD will continue to consult with the Health and Services Director.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3) · Plan of correction due date: Oct 31, 2022

87307 Personal Accommodations and Services-(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) had a shower chair to use for assistance during bathing from on/around April 2022- September 2022, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2022

Plan of correction: Resident received a shower chair end of September 2022. Licensee/Administrator agree to conduct staff training on proper protocols in reporting issues to managers. Documentation of agenda/attendees to be provided to CCLD by 10/31/22.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue a related deficiency to complaint # 25-AS-20211027124047 that was opened/closed under the facility's prior license that was open through 5/3/2021. Complaint findings for this complaint were issued on April 12, 2022. LPA met with Administrator, Kathleen Gilbey, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. This report was created to document today's inspection under the current license and that a $500.00 penalty is being issued to the facility pursuant to Health and Safety Code section 1569.49(c)(1) - a violation that resulted in the injury or illness of a resident. The violation occurred on July 2018. There are no deficiencies issued on this report. Exit interview. Copy of report left with Administrator.the state’s words, verbatim · CDSS document, Aug 30, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Kathleen Gilbey, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): N95 mask. The facility is licensed for 101 non-ambulatory residents and have a hospice waiver for 12 residents. There are currently 3 residents on hospice. LPA and the Executive Director toured the interior and exterior of the facility of the Assisted Living Unit (ALU) and Memory Care Unit (MCU) including the medication room, dining room, activity room and common areas. Also observed in the ALU area were the theater, library, salon, massage and physical therapy room. LPA observed the facility to be clean, in good repair and to be odor free and the bathrooms to have paper towels, soap and trash cans with lids. Facility to re-post hand-washing signs by each sink. Business Office Director maintains staff fingerprint associations regularly. Facility is limiting staff room to 2 staff at a time and windows are left slightly open. Fire extinguishers observed throughout and to have been last serviced on 8/6/2021. LPA observed 2+day perishable and 7+day non-perishable food in the kitchen and locked toxins in the laundry rooms. Facility has emergency lighting and a back-up generator. LPA observed hand sanitizers throughout and required postings displayed. Discussed vaccination protocols of residents and staff and visitation protocols in place. Booster #2 clinic scheduled for 5/12/22. LPA requested a copy of LIC308, LIC500 and current liability insurance be emailed to CCLD by 5/9/2022. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, May 2, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the receipt of (2) Incident Reports (LIC624). LPA met with Kathleen Gilby, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms;. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. Additionally, LPA was screened upon entering the facility. The following was discussed: Resident (R1) felt light-headed on 4/2/2022 and was sent to the emergency room due to low vitals. Resident returned the following morning with no medication changes. R1 was using portable oxygen at the time of being sent out. Resident (R2) moved to facility in March 2022 with a diagnosis of Dementia. Resident was not previously living in a facility but at home. On 4/5/2022, resident was able to remove the window alarm and open the window in the activity room and climb out into the facility courtyard that is fenced. R2 was discovered in the courtyard at 8:00 am, approximately 15 minutes later. A follow up meeting was held with resident's family to discuss a better placement for resident. Resident was not injured other than minor skin tears during the incident. Administrator contacted LPA on 4/6/2022 in the afternoon. It appears the facility acted promptly with both residents. There are no deficiencies being issued today. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Apr 12, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the investigation into the open complaint. LPA met with Kathleen Gilby, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms;. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA was screened upon entering the facility. While at the facility, LPA and Administrator discussed current Covid situation- last positive case (staff) has completed 10-day quarantine. Second round of response testing was conducted yesterday. Also discussed during today's inspection is the death of resident (R1) last Saturday, 3/5/2022. Facility submitted a completed incident report on Monday, 3/7/22. Resident was not receiving hospice services but had moved in recently to the facility. Administrator agreed to reach out to resident's family and request a copy of the county death certificate and provide to the Department when received. There are no deficiencies being issued today. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Mar 10, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection as a follow up to (3) incident reports that were recently received. LPA met with Kathleen Gilby, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA was advised of a positive staff case during today's inspection from 12/30-/2021. Staff last worked 12/27/202 and an incident report was sent to the Department on 12/31/2021. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA was screened upon entering the facility. The following incidents were discussed with Memory Care Director (MCD), Megan Leone, and also with Administrator, Kathleen Gilbey, with additional information obtained, as follows: Resident (R1) sustained a fall on 12/30/2021, fracturing her hip, and was sent out for emergency services immediately following the incident and returned on 1/4/2022, under hospice care. MCD stated that R1 believed that her walker was no longer hers and wouldn't use it regularly with ambulating, which caused her to fall in the dining room. Resident (R2) was administered a second dose of the evening dose of Nitrofurantoin to treat a urinary tract infection on 12/21/2021. Resident's physician was notified via fax by the facility and resident is doing well. Resident (R3) displayed combative behaviors with other residents in Memory Care on/around November 2021 and on several other occasions in the months prior. MCD stated that R3 was unable to communicate her needs and was placed on hospice in early December 2021. Resident was receiving medication for pain and her physician was advised of resident's behaviors. Resident passed on 12/26/2021 and was provided with a copy of the death report (LIC624A) that was faxed to the Department on 12/27.2021. It appears the facility took appropriate action following each incident. Discussed more complete documentation needed on incident reports submitted. There were no deficiencies found. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jan 5, 2022