Incident investigation·March 12, 2025

On 03/12/2025 at 9:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving a self report of suspected abuse (SOC341) of a resident having fallen in their room and caregivers not appropriately assessing. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. R1 was admitted to the facility on 2/22/25. R1 is in memory care . Report indicates that R1 had a fall on 3/3/2025 at approximately 3:23am and S3 was notified at 3:31am. S3 called S1 and S1 went to check on R1. Camera footage confirms that S1 went to check on R1 at 3:32am. S2 was on shift at the same time as S1 and was assigned to R1's room. After S1 checked on R1 they notified S2 that R1 was in bed asleep. S1 checked on R1 again at 3:34am. At 6:04 am S2 checked on R1. No injuries were reported until morning ADL's when it was discovered that R1 had blood on their pillow and R1 was sent out to the emergency room. LPA observed the video footage of R1's fall and them getting back into bed as well as the checks done by staff. S1 and S2 both received additional training as a result of this incident and were put on suspension pending an investigation. It was found that S1 did promptly check on R1 but that S1 should have woken R1 up to have a full assessment done. Both S1 and S2 received verbal warnings and in service training. R1 is currently back at the facility and is in physical therapy. No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.