Incident investigation·May 15, 2023

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to follow up on the incident occurred on 04/25/23 wherein Resident #1 (R1) was reported to have died of blunt force trauma. LPA conducted physical plant tour at around 9:45 AM, requested copy of facility documents relevant to the investigation at 10:35 AM and interviewed staff between 11:00 AM to 12:30 PM. LPA also reviewed records between 12:30 PM to 1:30 PM. LPA record review today between 12:30 to a:30 PM revealed that R1 had an unwitnessed fall on 04/09/23 at approximately 4:00 PM at own apartment. R1 was able to call family member who called 911 who picked R1 at the facility to bring to the hospital. Further record review revealed that R1 was ambulatory and did not need any assistance on Activities of Daily Living (ADLs) including showering, transferring, toileting, grooming, etc. LPA's interview with the Executive Director and staff today revealed that R1 returned to the facility on 04/19/23 with Hospice Care services and passed away on 04/25/23 while in the care of a Hospice agency. There is no immediate health and safety concern during this visit. Exit interview conducted. Copy of this report issued.