Incident investigation·August 30, 2022

On 8/30/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management regarding a serious injury incident report the Department on 8/23/2022. LPA Yang met with Executive Director, Lyndee Whaley, Terrence Club Coordinator, Rachel West and Resident Care Director, Christina Bond and explained the purpose of the visit. Prior to initiating the visit, 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. LPA completed a facility risk assessment upon arrival. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. On 8/19/2022, R1 was reported to have fallen when attempting to self transfer to the bathroom. R1 was found on the floor and 911 was called. R1 was reported to be in severe pain and was transported to UC Davis Medical Center. R1 was discharged from the hospital and returned to the community later that day. LPA interviewed with (4) staff and obtained copies of the visitor log of August 19, 2022 and August 20,2022, R1's resident profile, UC Davis After Visit Summary, R1's Death Report and Home Health Visit Report. As a result of today’s inspection, no deficiencies were noted. LPA reviewed the report with Executive Director and a copy was provided and left at the facility.