Incident investigation·April 18, 2024

On 4/18/2024, Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident that occurred on 4/14/2024. LPA reviewed special incident report dated 4/14/2024 stating R1 had an unwitnessed fall and as a result sustained a head injury requiring two staples. R1 has a history of falls and the facility has taken precautions to minimize R1 from falling. R1 has a current service plan that addresses the fall risk with home health services to assist with balance and ambulation. R1 moved in with a walker and is legally blind. During today's visit, LPA reviewed R1's file, medical records related to the fall and service plans dated 2/28/2023, 3/15/2023, 8/30/2023 and 3/19/2024. The facility appears to be exercising best practices with R1's service needs as it pertains to the fall risk mitigation. The department has requested by the close of business on 4/19/2024, an updated LIC 500 with actual times that the Administrator is on-site. Exit interview was conducted.