Incident investigation·April 8, 2025

At 2:35, PM Licensing Program Analysts(LPAs) Noel Wolf Petersen and Michael Bilger arrived and opened a case management regarding a unobserved falling incident and an observed falling incident. They met with the administrator and interviewed her and requested documents related to the two incidents of falling that occurred on 03/10/2025 and 3/12/2025. At approximately 7pm on the tenth of march 2025, a resident was observed to be laying on the floor by her bed. Resident stated she was trying to change into her pajamas when she lost her balance and fell. Resident was assessed for injury by the Med Tech, resident stated no injury or pain and was assisted back into her bed. The facility put her on regular status check, and assessed the living space for fall safety hazard, called the family, and scheduled her for a Primary Care Physician(PCP) visit for further evaluation. The needs and services plan was updated to meet the needs of the client after the PCP visit. At approximately 2:30pm on the twelfth of march 2025, a second resident had an observed fall, and the facility called 911 and documented the resident refused the ambulance, notified the family, and updated their needs and services plan as needed by the recommendation of the PCP. The LPA's went over the Needs and services plans and the incident report with the facility representative. After the LPA's reviewed available documents and interviewed staff regarding the incident and the intervention by staff it was concluded that the facility complied with relevant regulation involving their intervention practices and reporting requirements. The LPA's discussed the incident with the administrator, read the report, and delivered it to the facility administrator. No citation issued.