Incident investigation·June 28, 2022

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility on 6/28/22 to conduct a case management inspection for an incident report (LIC624) submitted for an incident occurring on 6/6/2022. LPA met with Interim Executive Director, Bill Phelps and later Susan Domke, Health and Safety Director and explained the purpose of the visit. Prior to initiating the case management inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. Additionally, LPA was screened by facility staff upon entering the facility. During today's inspection, LPA interviewed, Susan Domke, Health and Safety Director ,Regional Nurse, and staff, Jewell Harrell. in person and Felicidad Ibarra, by phone, LPA reviewed hospital documentation following the incident showing resident (R1) was admitted on 6/6/22 at 7:26 pm and discharged the same day at 9:16 pm with a diagnosis of fall, closed head injury and forehead abrasion. Hospital documentation notes that resident had a unwitnessed ground level fall, was bleeding from the forehead and CT scan showed "no intracranial trauma or acute fracture". Regional Nurse who completed LIC624 confirmed that resident was found outside on the enclosed patio by the caregiver after having an unwitnessed fall and that resident walks regularly in the hallways. Caregiver stated that resident walks around a lot inside, without a walker, and this was the first time she went outside on the patio. Caregiver stated that if the weather is nice, the door will be left open to the patio, encouraging residents to go outside on the patio. Caregiver stated she is not sure how resident fell and staff should provide 1:1 supervision if resident is walking outside. Health and Safety Director stated resident has a diagnosis of Dementia, is currently doing fine with no recent changes in medications and was not eligible for physical therapy due to the level of Dementia. There are no deficiencies being issued today. Exit interview. Copy of report provided to Administrator.