Incident investigation·August 27, 2021

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to an Incident report received in the Community Care Licensing (CCL) office on 8/17/2021. Upon arrival at the facility, staff took the LPA's temperature and documented the results. The incident report received, indicated a fall that occurred on 8/1/2021. The resident (R1) in question, was inspected by the facility nurse and checked for any abrasions, bruises, or injuries. The facility had made internal documentation of the fall and since there was no reported injury, the facility did not deem the fall as an unusual incident and therefore did not submit an incident report. R1's responsible party and primary physician were notified of the fall. On 8/8/21, when R1 did mention that R1 was experiencing pain, an unusual incident report was submitted to CCL, timely. At 8:15 am, the LPA spoke with the Resident Service Director, who is also a Licensed Nurse, and requested that all falls not only be documented at the facility, but an incident report be submitted to CCL as well. No deficiencies cited during this visit. Exit interview conducted and report issued.