Incident investigation·November 29, 2022

Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez made an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 11/28/2022. LPAs met with Executive Director Rosa Ayala and explained the reason for the visit. Incident report dated 11/21/2022 indicated Resident 1 (R1) had fallen to the floor after attempting to walk. The fall was captured on video surveillance. Facility LVN assessed the resident and called hospice who came out later that day. Hospice Nurse assessed the resident to be fine and provided pain medication. The next day resident was still in pain and was assessed by Director of Resident Care. R1 was observed to have swelling on the left hip and the leg was observed to be visibly shorter than the other leg. Mobile X-Ray was called out and resident was diagnosed with a broken left hip. During the visit, LPA Ramirez observed the resident resting comfortably. LPAs reviewed and obtained pertinent documentation such as physician report and hospice notes. Exit interview conducted and a copy of this report was left at the facility.