Incident investigation·February 6, 2025

02/04/2025 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Resident Care Director Jay Tippens. Today’s visit is regarding an incident report that was received by licensing on 01/16/2025 regarding an incident that occurred on 01/09/2025. It was reported that on 01/09/2025 8:00 PM staff reported that Resident 1 (R1) was observed on the floor of their room. R1 expressed pain in left shoulder. EMS was called to evaluate and transported R1 to Oroville hospital. R1 was diagnosed with fracture to ribs and left shoulder and admitted to Oroville Hospital. Resident was subsequently admitted to skilled nursing for rehabilitation. During the investigation it was learned that staff does rounds and checks on assisted living residents at 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. R1 was brought tray service to their room at approximately 6:30 PM that night. R1 was observed on the floor of their room during 8:00 PM rounds. Staff followed all fall protocols, since R1 complained of shoulder pain staff did not move R1 and called EMS. R1 is still in skilled nursing for rehabilitation. Facility staff are visiting R1 at SNF once per week to assess R1's condition. LPA inspected R1's room and no trip hazards were noted. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to Resident Care Director Jay Tippens.