Incident investigation·September 19, 2024

On 9/19/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report that was received. LPA Jensen met with Executive Director Jacob Harryman and Memory Care Director Angelica White. LPA Jensen received an incident report wherein an assisted living resident (R1) reported vomiting black blood. LPA Jensen reviewed R1's Physician's Report (LIC 602), Pre-Admission Appraisal, Medication Administration Record (MAR), Needs and Service Plan, Progress Notes and incidents reports from 2024. LPA Jensen observed an LIC 602 that indicates R1 requires a mechanical soft diet. LPA Jensen also observed that the Needs and Service Plan did not indicate any kind of special diet requirements. As a result of record reviews and interviews conducted with the Executive Director and Memory Care Director it was learned that R1's LIC 602 was completed when R1 left a skilled nursing facility and mechanical soft diet was no longer required after he returned to the facility. A physcian's order for regular diet is now on file. It was also learned that the incident reported was unrelated to R1's dietary needs. LPA Jensen provided technical assistance and recommended that all LIC 602's are checked for accuracy, updated as needed and that facility staff should ensure that Needs and Service Plans reflect the physician report indicators. No citations were issued as a result of this visit. An exit interview was conducted and a copy of this report was provided.