Incident investigation·February 24, 2022

On 2/24/2022 at 1:00PM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a case management on two incident reports received related to falls, LPA met with Executive Director/Administrator Cliff Keene and explained the purpose of the visit. Prior to initiating the annual 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; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask LPA reviewed an incident report that detailed an incident that occurred on 1/8/2022. On this date a resident (R1) fell out of bed resulting in the need for medical attention. LPA discussed the residents diagnosis with Administrator. ONR (occupational therapy) assessed him for a change in condition. R1 has not had a fall since. LPA reviewed an incident report that detailed an incident that occurred on 1/10/2022. On this date a resident (R2) tripped on her own feet, falling and resulting in complaints of pain to shoulder and head. R2 refused to be transported by EMS. LPA discussed the incident with Administrator who stated the occupational therapist assessed R2 for change in condition and assessed R2 for fall risk. Administrator said since the incident R2 has not had another fall and is still receiving physical therapy. No deficiencies cited.