Incident investigation·February 8, 2022

Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with Administrator, Wendy Watson. LPA is following up on two self-reported incidents involving residents, R1 and R2. Resident, R1 had an un-witnessed fall on December 8, 2021 resulting in an injury that caused resident to be admitted into the hospital. Resident declined surgical repair and returned to the facility on hospice. Resident, R2 had an un-witnessed fall on January 2. 2022. Per staff interview and incident report, R2 refused to go to the hospital despite facility staff offering multiple times. Due to increased pain, resident did go to the hospital on December 7, 2022 where they were diagnosed with a fracture. Resident has returned to the facility and is receiving follow-up care Based on file review and interview, neither resident required one-to-one assistance. No deficiencies cited during this inspection.