Incident investigation·April 15, 2022

On 4-15-22 at 3:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Maja Jensen arrived unannounced to conduct a case management visit for an incident reported on 3-3-22 which occurred on 3-2-22.. LPA met with Resident Care Coordinator (RCC) and explained the purpose of the visit. Administrator Alma Whitted was informed of LPAs visit and gave permission for Andrea to sign in her absence and accommodate LPAs. LPAs reviewed incident report with RCC and interviewed RCC. Based on record review and interview it was determined that Resident1 (R1) was sent to the hospital on 3-2-22 after experiencing shortness of breath and a fall while in the shower. R1s shortness of breath and fall occurred at 12:30pm on 3-2-22 and 9-1-1 was notified by staff. R1 was then transported to acute hospital at approximately 1:00pm and officially admitted on 3-3-22. R1 remained in hospital until 3/14/22 at which time R1 was transferred back to facility and began receiving hospice services on 3/14/22. On 3-22-22, licensing department received a death report stating R1 expired on 3/19/22 while under hospice care due to acute cebrol vascular stroke. Based on record review it was determined that reporting requirements and emergency procedures for above incidents were followed appropriately. No deficiencies cited during today's visit. An exit interview was conducted with Andrea Eldridge and a copy of this report was left with Andrea.