Incident investigation·May 18, 2022

Licensing Program Analysts (LPA) Mai Thao and IB Investigator Melissa Bennett arrived at the facility to conduct an unannounced case management visit. LPA met with Sarah Thomas, Residential Service Director and Ivy Garner, ED in Training. LPA explained the purpose of the visit. Prior to initiating the case management visit, LPA and IB Investigator completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA and IB Investigator ensured they wash their hands before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 and surgical mask. In addition, Staff screened LPA and IB Investigator prior to entering the facility. It was reported to Licensing on January 6, 2022 that on 12/25/2022, Resident 1 (R!) had an unwitnessed fall, was sent out to the Emergency Room (ER), and sustained a fracture. During today's visit, LPA, IB investigator, RSD and ED in Training discussed the incident. Through record review, it was observed that R1 was under the care of Hospice. RSD and ED in Training stated that resident was on a precaution 2 hour checks that were documented on logs. RSD and ED stated that R1 is able to use the bathroom independently and may require stand-by assist if needed. LPA and IB investigator reviewed R1 LIC 602 Physician's Report and Care Plan. LPA did not observe R1 activities of daily living (ADLs) being address. LPA advised facility on updating care plans to meet changes in condition. LPA observed that R1 had a Hospice Care Plan on file. LPA observed on facility documentation that staff last checked on resident at 6:55pm and at 7pm staff heard resident calling for help. The facility immediately went to the resident, assess the incident, and contacted 911. No citations were observed during this visit. An exit interview was conducted and a copy of this report was left at the facility.