Incident investigation·November 13, 2025

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver case management findings. LPA was greeted and granted entry and explained the reason for the visit. The Department received an Unusual Incident/Serious Injury Report on September 12, 2025, for an incident that occurred on September 10, 2025, with Resident 1 (R1). LPA Mendivil conducted a case management visit on September 16, 2025, and gathered admission agreement, medication administration records for R1, care notes and staff schedule. The course of the investigation revealed the following: R1 was admitted to the facility on January 12, 2025. Per review of R1’s level of care effective on August 31, 2025, stated R1 is a fall risk and staff were to provide safety checks and remind R1 to use their walker when ambulating. R1 has a diagnosis of senile dementia, hypertension and falls based on R1’s physicians report dated January 11, 2025. On September 10, 2025, around 6:30pm, R1 had an unwitnessed fall in the Memory Care common tv room. Staff 1 (S1) reported they were assisting another resident that pressed the egress door at the time of the fall, approximately 20 feet away from R1. When S1 came back into the living room area they observed R1 to be on the floor next to the recliner they were previously sitting on. It was reported that S1 asked for assistance from other staff to assess R1. R1 was observed to have a small skin tear on elbow and expressed pain upon moving their right leg. It was then reported that the facility called 911 and the resident was taken to the hospital where they were diagnosed with a hip fracture. Prior to hospitalization, incident reports reviewed showed R1 had six separate falls which resulted did not result in any serious bodily injuries until the fall on September 10, 2025. Based on interviews with Executive Director Christian, it was reported that R1 had 2 assessments one at admission and once again in August of 2025. Per review of incident reports for falls on January 28, 2025; March 17,2025; March 25, 2025; April 16, 2025; May 14, 2025; May 18, 2025; July 07, 2025; August 02, 2025; and September 10, 2025; staff assessed R1 following falls. In addition, R1’s family and physician were notified. Per interviews with R1’s physician assistant (PA) it was reported R1 had significantly more falls at their previous facility and the PA stated they did not feel facility staff were neglectful or provided inadequate care for R1. Therefore, based on evidence through records reviewed and interviews, the Department could not corroborate if neglect/lack of care and supervision caused R1’s fall and injuries. No deficiencies are being cited. An exit interview was conducted, and a copy of this report was provided to Executive Director.