Incident investigation·March 26, 2025

On 03/26/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit in regard to an incident report. LPA met with Executive Director (ED), Cayia Peevy and Health and Wellness Director, Kuldip Singh. LPA explained the purpose of visit. Based on the incident report dated 03/21/2025, at around 5:30AM on 03/16/2025 staff responded to the emergency pull cord. Resident (R1) had an unwitnessed fall. R1 reported to staff that the fall happened in the living room of his apartment, he was able to get himself up and walk into his office and called for help, when R1 started to feel pain in right hip. Staff called 911 and R1 was transported to the hospital. During visit, LPA interviewed staff and reviewed R1’s file including physician's report and incident report. R1’s physician's report stated that R1 does not need assistance with transporting or ambulating. Interview with staff revealed that R1 sustained a broken right hip as a result of the fall and after right hip surgery R1 was admitted to skilled nursing facility on 03/19/2025. Staff also stated R1 was independent prior to fall and required no assistance with ambulating or ADLs, R1 is back in the community and has been very social, participating in activities and comes down for meals daily. No deficiencies sited during visit. Exit interview conducted and a copy of this report provided.