Incident investigation·May 4, 2023

LPA arrived at this facility unannounced, to conduct a case management visit in regards to two unusual incident reports and two death reports submitted to CCL. LPA met with Administrator Colleen Rasmussen and reviewed records. Incident 1: Staff heard a loud noise from the room of R1. Staff responded to find R1 sitting on the floor next to their chair. R1 stated they tried to sit in the chair and missed it, landing on the floor. R1 stated they were not in pain at that time. The following day staff took R1 to the hospital as they observed swelling on their arm. R1 was diagnosed with a closed fracture dislocation of the right elbow. Treatment was provided and a cast was applied. Incident 2: R2 fell in the restroom, hitting their eye on the wall. Staff assisted R2 and applied first aid. R2 was taken to the emergency room and received 3 stiches. Death 1: R3 was in the hospital at the time of death. Based on a review of their latest physician report, their health was declining and were in poor health. Staff observed R3 having difficulty breathing and contacted emergency personnel to respond. R3 was transported and taken to ICU. Facility staff responded correctly, per regulation, to ensure R3's medical needs were met. Death 2: Staff observed R4 at breakfast, then in their room watching TV. Staff checked on R4 again and found them unresponsive with no pulse. R4 was in poor health and declining per latest physician report. No citations issued during this visit.