Incident investigation·November 23, 2021

On 11-23-21 at 9:56am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit due to incident reports received on 11-19-21. LPA met with Resident Care Coordinator (RCC) Ian Phitsanoukanh explained the purpose of the visit. Licensee was on premises and gave permission for Ian to sign and accommodate LPA during today's visit. LPA conducted a health and safety check during case management visit. LPA's temperature was checked and logged at entry. Sign in procedures were initiated. Facility temperature was 75*F throughout facility. Staffing included 3 caregivers in memory care and 1 med tech, 2 caregivers in Assisted Living and 1 med tech. Resident were eating lunch at 11:50am and served according to mealtimes and menu items. At 10:05am LPA reviewed 14 incident reports received on 11-19-21. 4 out of 14 incident reports were reported as unwitnessed falls. LPA also reviewed facility’s fall prevention program and conducted interviews with Resident1 (R1), Staff1 (S1) and S2. LPA also conducted observation of R1 relating to self-administered medication procedures at 12:45pm and reviewed medication log sheet and physician’s report for R1 at 12:10pm. Based on interviews and record reviews it was determined that R2, R3, R4, R5, and R6 are receiving fall prevention services. Based on review of medication log sheet, incident report, interviews, and observation it was determined that R1 is able to administer own medications accurately. Additionally during review of incident report, it was determined that 6 of 14 incident reports were submitted to regional office beyond seven days of occurrence and not within reporting requirement regulations. As a result of today’s visit, deficiencies are cited per Title 22 regulations, division 6, chapter 8. A civil penalty in the amount of $250 is assessed due to a repeat violation. An exit interview was conducted with Ian Phitsanoukanh and a copy of this report was left with Ian. Appeal rights provided.