Incident investigation·January 9, 2024

In conjunction with a Case Management (CM) for the previous facility number, #197609862 (see LIC 809 dated 01/09/24-closed/change of ownership, Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit for an incident that occurred the same day (01/09/24) at the current facility license number (197610318). During the CM visit, Resident 1 (R1) had a fall. As a result, R1 was experiencing and complaining of pain. Family member and hospice nurse was present. According to the hospice nurse, hospice protocol for the facility is to notify the hospice agency first, if incident is non-emergency and non-life threatening. Nurse made their assessment, and incident is not considered life threatening and/or non-emergency. Nurse stated, non-emergency medic was called and they are awaiting their arrival for further assistance. LPA questioned the administrator on why 911 was not notified. Administrator stated, the last time emergency paramedics were called, paramedics were upset at him, asking him why he did not adhere to R1's hospice care plan, and advised them to refer to R1's hospice care plan for non-immediate emergency. P er administrator, this is only R1's second fall since being admitted. R1 has no history of falls. LPA advised administrator to submit an Incident Report (IR) to the Licensing Agency to satisfy their reporting requirements. No citations issued at this time as facility appears to adhere to R1's hospice plan, and to provide R1 with the assistance they need.