Incident investigation·December 12, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a follow up case management inspection and met with Julie Smith and Jenice Beecher, caregivers, who indicated the Administrators were currently out of town. LPA stated the reason for the inspection was to follow up on several incident reports (LIC624) submitted to the Department since November 28, 2025 for resident (R1). LPA reviewed LIC624 for November 25, 2025 (1:40 pm) when (R1) fell while walking with their walker from the patio to their room. Staff, Jenice, assisted (R1) to get up and noticed a bump on their left side of the head and provided Tylenol and an ice bag. Family was notified and stated they would check on (R1) tomorrow. The same incident report notes that (R1) felt dizzy when trying to get up, on November 26, 2025, and wanted to see their physician, so the family took them to the Emergency Room at 3:00 pm. (R1) had multiple tests taken and returned to the facility around 9:00 pm. On November 27, 2025, staff, Julie, assisted (R1) get up from an unwitnessed fall around 3:30 pm in their room. Staff observed resident's right ankle to be swelling and provided Tylenol and ice. The administrator contacted family who stated they would visit (R1) the next day. On November 28, 2025, staff observed (R1) to have worsening pain with swelling/bruising on their right ankle, and unable to bear weight. Family was contacted and took (R1) to Urgent Care in the afternoon, where it was determined (R1) had a fractured right ankle and was sent to the Emergency Room for an Orthopedic Consult. (R1) returned at 1:00 am the following day with a splint on their right leg. RR1) requested to be seen at the Emergency Room on December 2, 2025 due to dizziness, had multiple tests completed, and obtained an orthopedic boot the following day. Hospital discharge papers do not note any medication changes were made. All tests were negative. (R1) returned to the facility (4) hours later, with a follow up appointment with their primary care physician the next day. *cont on 809C-1. . 809C-1... The administrator stated in an email on December 4, 2025 that (R1) was fitted for an Orthopedic boot they will wear for (4-6) weeks. In addition, Physical Therapy was ordered, and (R1) will have a follow up X-ray in (4) weeks. The facility provided supporting documentation as requested to the department. Paperwork from (R1's) Urgent Care visit on November 28, 2025 noted (R1) had a right ankle sprain/fracture from a fall the previous day and did not strike their head; however, (R1) did strike their head during a previous fall (3) days prior, but a CT scan was done and confirmed there was no injury noted. LPA reviewed (R1's) care plan that was updated December 2, 2025 , after (R1) reported dizziness and had multiple tests completed. The care plan addresses the right ankle fracture and lists (6) ways the facility will provide appropriate interventions in the areas of: Mobility, Pain Management, Safety Measures, Follow-Up care, Emotional and Social Support, and Nutrition and Hydration. The care plan also documents that all care staff will be informed of (R1's) non-weight bearing status and limitations. The care staff today indicated that (R1) has begun receiving Physical Therapy services and will begin to be seen twice weekly, beginning next week. Staff stated (R1) is using a wheelchair and is receiving bathing once a week while the ankle heals. The care staff stated she had not fallen in a long time and suddenly fell on November 25, 2025 and stated (R1) wanted to use the bathroom independently and fell. LPA observed (R1) to be wearing the orthopedic boot on their right foot and resting in their room watching television. LPA observed (R1) to be in a pleasant mood. LPA observed (2) other residents to be awake, watching television and (1) resident to be sleeping. It appears the facility took appropriate measures in contacting the family and emergency medical services after (R1) fell on each occasion. There are no deficiencies issued in this report. Exit interview with Jenice Beecher, who is authorized to sign. Copy of report provided.