Incident investigation·January 29, 2026

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Terry Bechtold, Executive Director (ED) & (HSD) Health Services Director, Tosha Chowdory. The purpose of the visit was to follow up on two self-report incidents submitted to Community Care Licensing (CCL). On 12/26/25 the department received the first incident report notifying about resident (R1) who on 12/20/25 was admitted to the hospital after their responsible party transported them to the hospital for further evaluation due to pain. On 1/27/26 a second incident report was received at CCL reporting that on 1/22/26 R1 was found on the toilet of their bathroom shaking, vomiting and screaming in pain. Staff called 911 and paramedics arrived, R1 was given pain medication through IV and they transported R1 to the emergency room for further evaluation. Responsible parties were notified. Per incident report, R1 had some imaging and testing done, which indicated a diagnosis of uncontrolled pain secondary to fractured hip, then R1 had surgery on 1/23/26 to repair their hip. Upon discharge from the hospital, R1 will have to go to a skilled nursing for rehabilitation. During today's visit, LPA learned through a conversation with HSD and ED that R1 had a fall outside of the community back in December while walking with their private companion. At that time, there were no complaints of pain until days later, R1 complained of pain in their hip, and their physician was waiting on an opening to schedule a surgery. Continued on LIC809C... Continued from LIC809... Based on records review, the facility provided internal incident report dated 12/1/25 at 1:15pm, there was an incident documented for R1 who had a witnessed fall off the community property while walking with their companion. According to the description of the incident, companion stated that R1 fell onto the ground more on right wrist and caught themselves from hitting ground, but did graze their upper lip. After the fall they spent few hours at R1's house. The assessment was performed by the facility indicating skin tear of R1's right wrist, which did not require any emergency services. R1 was added to the alert chart and incident was documented in the resident's progress notes. LPA reviewed R1's progress notes that confirmed there were no complaints of pain at the time of assessment. However, on 12/15/25 R1 complained of right hip pain, the facility notified their physician who prescribed Lidocaine patch, but pain increased through the days affecting their mobility. R1's responsible party requested the facility that they prefer not to send R1 to the emergency room because they were under the impression that they could mange their pain with medication and they did not want to cause any distress to R1 due to their progressed dementia. Although, R1's physician instructed the facility to send R1 to the hospital for pain management. On 1/2/26, R1 returned to the community requiring a higher level of care until they undergo surgery. Their diagnoses confirmed a status of post advanced degenerative arthritis of the right hip with pain, fracture of the right femur, fracture of the left wrist, Alzheimer disease and depression. The facility updated R1's care plan accordingly, care managers were updated of R1's higher care needs including behavioral expressions like impulsiveness and consistency of forgetfulness by not asking for assistance. On 1/27/26, R1's physician notified the facility that R1 had an insufficiency fracture as a reason why they did not perform surgery right away. On 1/28/26, R1 had a total hip replacement and they might have to go to skilled nursing for at least a couple weeks until returning to the community. Based on records review and interviews with facility staff, it was determined that the facility followed up their protocol. No deficiencies were cited during today's case management visit. Exit interview was conducted and a copy of this report was given to the Executive Director.