Incident investigation·August 1, 2025

On 08/1/2025 at 8:30AM Licensing Program Analyst (LPA) A Gomez conducted an unannounced Case Management visit regarding a self-reported incident. LPA met with Resident Care Director (RCD), Ashley Paris, and explained the purpose of the visit. A self-reported incident report was received on 7/25/2025 from facility that indicated Resident 1 (R1) complained of pain however they had not had a fall and after visit summary indicated that the resident had a hip fracture. During the visit, LPA interviewed RCD. RCD states that R1 did not have a fall however during morning transfer they maneuvered in a way that caused the injury. The maneuver was common for R1 while being transferred and R1 did not immediately disclose any pain. When R1 did disclose discomfort their responsible party was notified and they were later sent out to the hospital. RCD states that R1's physician verbally told them that R1 was pre-disposition to this new injury due to them having a prior fracture in the same area. RCD also states that the doctor stated that they observed the area with the fracture to have Osteoarthritis which also contributed to R1 becoming injured. R1's care plan has since been updated to include a hoyer lift during transfer to elevate future strain and minimize R1's maneuvers during transfer. No deficiencies cited during visit. Exit interview was conducted with Resident Care Director and a copy of this report was provided.