Incident investigation·March 5, 2025

At approximately 11:15 a.m. on 03/05/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit was conducted after the facility submitted an incident report regarding Resident #1 (R1) having a fall outside of the community while intoxicated. LPA toured the facility at 11:20 a.m. today, interviewed staff and residents between 11:30 a.m. and 1:00 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 12:00 p.m. Interview with Staff #1 (S1) at 11:45 a.m. today revealed some residents have a drinking alcohol in the facility at night. Record review of R1’s medical assessment revealed they are able to leave the facility unassisted and do not have a substance abuse problem. Interview with Staff #2 (S2) at 12:15 p.m. today revealed staff are aware of multiple residents drinking alcohol in the facility. S2 further stated that staff have not received training on providing care and supervision to residents with substance abuse problems. Interview with the administrator today at 1:30 p.m. revealed the facility can issue a training for all staff on dealing with substance abuse issues as well as updating the facility program plan to address care of residents with substance abuse issues. Exit interview conducted. Copy of report provided.