Incident investigation·December 9, 2022

On 12/9/2022, at 10:45AM, Licensing Program Analysts (LPAs) L. Fici and J. Clancy-Czuleger arrived unannounced to conduct a case management visit for a death that occurred on 10/20/2022. LPAs was greeted by Joyce Welch, Administrator (ADM) and Marrissa Okolo, LVN and explained the purpose of visit. LPAs received a death report that was submitted to CCL on 10/21/2022. LPAs requested the following documents, admission agreement, hospice plan and notes, hospice orders, incident report of fall, residents MAR log, physicians report, and SNF discharge paperwork. LPAs interviewed ADM and LVN regarding the death. Resident had a fall on 10/2/2022, and was admitted to the hospital. On 10/10/2022, resident was placed in skilled nursing facility (SNF) and was discharged back into Cogir of Fremont on 10/14/2022. Resident passed on 10/20/2022. Hospice death report lists cause of death to pre-existing condition. During record review, LPAs observed medication was being given by hospice and the facility correctly and followed physicians orders for medication administration. No deficiencies cite at this time. Exit interview conducted with ADM and LVN, and a copy of this report provided.