Incident investigation·May 29, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to do case management visit . LPA met with Administrator, Stephen Macdonald and explained the purpose of the visit. Department followed up on SOC 341 sent by facility on 05/24/24 for date -05/20/24 regarding resident, R1 where R1 alleged that R1 fell into the bed on 05/20/24 around 10.30pm when staff S1 and S2 were assisting them. Facility notified R1s responsible party, law enforcement and long term care ombudsman (LTCO) regarding this incident. Per facility records, there were no visible injuries to R1 after this incident. Per facility’s staffing records, S1 was not working on 05/20/24. LPA conducted interview with resident, R1 regarding this incident during today’s visit. LPA attempted to interview S2 but found out that S2 was not working today. LPA requested documents related to this incident and facility will submit all documents by 05/31/24 by 5pm. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.