Incident investigation·August 31, 2021

Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA Gurriere was screened by administrator/staff person upon entering the facility. On 05/04/21 it was reported that a resident (Resident 1) had an unwitnessed fall and was found laying on the ground in his room. The resident suffered a head injury and a humeral fracture. The resident was transported to the hospital. Later that day, the resident was returned to the facility. The resident was advised to not use the restroom unless he had supervision. Resident was placed on hospice and then passed away approximately one month later. On 05/16/21 it was reported that a resident (Resident 2) had an unwitnessed fall and was found on the floor in his room. The resident had a laceration on the back of his head. The resident was sent to the hospital and returned later on the same day. The resident did not need sutures and is doing well. The resident is currently on 15 minute checks. An exit interview was conducted, and a copy of the report was given to the administrator. No deficiencies cited.