Incident investigation·March 2, 2023

Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived at Carlton Plaza for an unannounced case management visit on Thursday, March 2, 2023 in response to an unusual incident report for a resident (R1) who fell on February 3, 2023, suffering a fractured wrist. LPAs Moleski and Lund met with executive assistant Krystal Cosaino and explained the purpose of the visit. LPAs Moleski and Lund requested and reviewed the facility's LIC 500, R1's resident records, and R1's care plan. LPAs requested to speak with R1, as well as S1 and S2, but were unable to do so. R1 is still in skilled nursing for her injury, and S1 and S2 were not working at the time of the visit. LPAs Moleski and Lund requested an updated LIC 500 from the facility, and an updated care plan for R1. No deficiencies were cited during this visit. An exit interview was held and a copy of the report was left with Cosaino.