Incident investigation·April 23, 2024

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 04/08/2024. Upon arrival, LPA was greeted by front desk staff, Lyn. LPA met with Business Office Manager Miguel Lino and explained the reason for today's visit. Executive Director (ED) Elizabeth Spencer arrived shortly after the visit began. On 04/18/2024, LPA Dulek received a voicemail from ED Spencer asking for a call back related to an incident that had occurred at the facility. LPA and ED spoke over the phone on 04/19/2024. During the telephone conversation, ED explained that there had been an incident on 04/08/2024 involving Resident #1 (R1). Another resident had backed up their scooter while R1 was ambulating using their walker, causing R1 to fall and hit their head. R1 was hospitalized following the incident and ED was made aware by R1's family that R1 had passed away at the hospital. Written incident report and death report were faxed to the Regional Office on 04/19/2024. During today's visit, LPA interviewed ED related to the incident and LPA, along with ED, toured the pertinent areas of the facility at 10:40AM. No immediate health and safety hazards were identified during today’s visit. LPA also reviewed R1's file and obtained copies of pertinent documents, and interviewed staff from 11:34AM to 12:00PM. LPA may return at a later date if further investigation is needed. No citations issued. Exit interview conducted. A copy of today's report was provided.