Incident investigation·April 1, 2025

On April 1, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management and met with Administrator . The purpose of the visit was to follow up on the visit dated March 27, 2025. The incident under investigation involves that, on 3/17/25, the department received an incident report for R1's fall with injury requiring hospitalization, on 3/14/25 at approximately 8:30 PM. While hospitalized, R1 was diagnosed with a hip fracture and to have contracted c-diff. R1 returned to care with Hospice, on 3/16/25. R1 passed away on 3/23/25. On March 27, 2025, LPA interviewed Administrator, S1 and R1 as well as requesting records. Administrator and S1 stated that R1 fell on 3/14/25 while using a walker and tripped on the way to the bathroom. Other interviews found that R1 fell while not using a walker. Additionally, at the time of R1’s fall, live-in caregiver was in the shower and unable to hear R1’s roommate, R2, calls for assistance. R2 got out of bed after R1 fell and went to alert S1 to R1’s fall. Following review of records and additional interviews, the department issued the following findings. Report continued R1 was admitted to the facility on February 28, 2025. At the time of admission, R1’s 8/19/24 physician’s assessment listed R1 as having , major neurocognitive disorder, documented as ambulatory, had a prescription for melatonin 5 mg. "half hour before bedtime”, audio impairment, visual impairment, bowel and bladder impairment and motor impairment. R1’s appraisal completed by facility staff on 3/3/25 noted: trouble walking, sometimes trouble speaking coherently, confusion/ forgetfulness, Non- Ambulatory, unable to walk without physical assistance, frail/slow, "Total Care", help with bathing, dressing and moving about the facility. The physician’s assessment does not identify R1’s extent of sleeplessness ,nor does the needs and services address a fall risk intervention for R1. R1 had sustained a prior fall with injury on 3/9/25. Incident report submitted stated that R1 had rolled out of bed and hit their head. Hospital discharge summary stated that R1 sustained a cervical spine injury for which R1 was to wear a neck brace for 10 days. Statements collected found R1 was not compliant to wear the brace. In addition to lack of supervision for R1’s safety needs, it was found that: R1 had an appraisal/ needs and services plan dated 3/4/25 that identified hospice serves, however, R1 did not start hospice services until 3/16/25, R1 has a prescription for Melatonin to be given at a half hour before bed though medication records logged melatonin given at 4 PM; and overnight staff have a room on the second floor but there is no signal system in place for residents to call for assistance if needed. Report continued. Due to a physician’s report that was not current to R1’s level of care, resident records lacking required information and staffing insufficient to monitor R1’s safety, The Administrator did not fulfill their duties as required. As a result of this investigation, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. A $500 civil penalty was assess. Further civil penalty may me reviewed/ assessed. Report reviewed. Copy of report and appeal rights provided