Incident investigation·March 12, 2025

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 02/25/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 02/13/2025 indicated Resident 1 (R1) had an un-witnessed fall in the hallway and was observed to have hip pain. 911 was called and resident was transported to the hospital and was diagnosed with right hip fracture. Resident had surgery to repair hip and admitted back to the facility on 03/01/2025. Per physician report dated 11/05/2024, resident is diagnosed with Dementia. Resident assessment dated 01/31/2025 indicates fall concern. LPA observed no other documented falls. Administrator states resident is on frequent checks, four times per shift, when not in common area of memory care unit. LPA viewed the area where the fall took place and observed no concerns. LPA spoke with resident who appeared well taken care of and verbalized feeling safe at the facility. Exit interview conducted and a copy of this report was left at the facility.