Incident investigation·September 29, 2021

Licensing Program Analyst (LPA) Lopez conducted an unannounced Case Management- Incident inspection and met with Kayla Young, Assistant Executive Director. The purpose of this case management inspection was to follow up on self reported incident report submitted to Community Care Licensing (CCL). On 9/7/21, facility reported Resident R1's fall incident with injury. Facility called 911 and was transported to Emergency Room. Facility reported to responsible party, 911,and Community Care Licensing (CCL). On 9/20/21 R1 stated that an employee from Carpet Crew went in room and hit R1 on head and that was the reason R1 fell on 9/7/21. SOC341 was filed and was sent to Ombudsman and Police but not CCL. LPA requested SOC341. Facility did send Incident Report for this incident. Facility conducted internal investigation, contacted doctor, responsible party, Ombudsman, Police and CCL. During visit LPA Lopez requested documents and took statements from Assistant Executive Director and nurse who was first to see him during incident and R1. Documents obtained by doctor disclosed that R1 had UTI and delusion. Lab work documents were obtained. Carpet Crew was also not working on the floor where resident stated was hit. LPA will gather information and will follow up with facility. No deficiencies cited during this inspection.