Follow-up·November 20, 2023

On 11/20/23 at approximately 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report received. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit. On 10/26/23 the Department received an incident report indicating that Resident 1 (R1) had an unwitnessed fall. Per facility protocol for unwitnessed falls, the resident was taken to the Emergency Department of the hospital and it was determined that she sustained a spinal fracture to L2. LPA Jensen interviewed the Executive Director and R!. LPA Jensen reviewed records including the Plan of Operation, R1's physician report, charting notes, pre-placement appraisal and needs and service plan. LPA Jensen observed lunch service during the course of the visit. During the annual inspection of 9/14/23, the facility was cited for a signal system in-operability and/or malfunctioning. The facility requested an extension for the plan correction through December 13, 2023. LPA Jensen discussed the facility's need to have an alternate plan for care and supervision so that resident needs can be met while the signal system is being upgraded. Technical assistance is being provided in the areas of signal systems, plan of operations and special diets. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Theresa Pettapiece and and a copy of this report and appeal rights were provided.