Incident investigation·June 14, 2022

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report received by Community Care Licensing (CCL) on 06/03/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit. Executive Director Eric Medor and Health Services Director Sheila Nazareth were present during the visit. Incident report dated 06/06/2022 indicated Resident 1 (R1) was heard by staff to be calling for help. Staff responded and the resident was found on the floor. Resident stated that the resident had fell and was complaining of back pain. 911 was called and resident was transferred out. R1 was diagnosed with a closed fracture of the 11th thoracic vertebrae. R1 was transferred back to the facility with pain management and no further intervention required. Urinalysis conducted on resident indicated a positive result for urinary tract infection. Resident tested positive for covid on 06/13/2022 and is currently on quarantine with a care companion. Physician report dated 07/01/2021 indicated a diagnosis of Dementia with intermittent confusion. Service assessment dated 05/02/2022 indicates episodes of unsteady gait with vertigo however did not require assistance with transfers or additional status checks. Facility states resident was on two hour checks, wore a pendant, and was on escorts. R1 had a prior fall on 01/13/2022. No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.