Incident investigation·September 5, 2023

Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident that occurred on 8/31/2023. Later joined by Rachel Ray and Rolando Santiago. LPA reviewed special incident report dated 8/31/2023 stating R1 had an unwitnessed fall and as a result sustained a Peri-orbital laceration. R1 has a history of falls and the facility has taken precautions to minimize R1 from falling out of bed. However, R1 has an outdated IPP and the facility has requested a meeting to updated it's plan for R1 to ambulate around the facility with her own wheelchair or a walker. R1 moved in without any medical equipment including medical alert bracelet. During today's visit, LPA reviewed R1's file, medical records related to the fall and IPP which is dated 5/31/2022 on 9/1/2023 the facility requested an emergency meeting for evaluation. Exit interview was conducted with Staff.