Incident investigation·October 3, 2023

Licensing Program Analysts Bertozzi and Coppo arrived unannounced to complete a case management inspection. LPAs met with Executive Director Jeannette Kinney. LPAs requested and reviewed resident files for two residents. LPAs are following up on self-reported incident report for R1. Per incident report resident was transported to the hospital following a positive COVID diagnosis and because of additional health concerns. LPAs reviewed resident's care plan which indicated that the facility's health concerns were documented in R1's care plan. Additionally, the resident was under the care of a third party home health care agency. Per special incident report R2 recently fell on bathroom floor, resulting in a head laceration and fracture. Incident report indicates resident was confused and vomiting. R2 was sent to the hospital 9/11/2023 and later passed away. Resident did not need one to one supervision per their care plan.