Incident investigation·September 28, 2023

09/28/2023 12:35 M Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Administrator Irene Davis. Today’s visit is regarding an incident that occurred on 09/16/2023 and was reported to licensing on 09/23/2023. It was reported that on 09/16/2023 at 7:10 PM Care staff was transferring Memory Care Resident 1 (R1) to the toilet and R1 slipped and fell on their bottom. Staff assessed R1 for injuries, none were noted but R1 complained of hip pain. The Med Tech called EMS and R1 was transported to a local hospital for evaluation and treatment. R1’s POA was notified. R1 was admitted to the local hospital to be treated for a compression fracture to their right hip. R1 will not be returning to the facility and will be admitted to skilled nursing as R1 is not cognitively aware enough to care for their hip and prevent further complications. LPA interviewed administrator and Memory Care Director during the visit. LPA obtained documents during the visit. LPA will conduct telephone interview with staff and return for a follow up visit. No deficiencies were cited as a result of today’s visit.