Incident investigation·January 23, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for today's inspection was to discuss (1) incident report recently submitted to the Department involving resident (R1). LPA also completed an interview related to a collateral visit. LPA and RCC discussed the incident when (R1) fell on January 21, 2026 (3:30 am). After falling (R1) yelled for staff assistance and staff promptly found (R1) on the floor in their room, complaining of severe pain on their right hip. Hospice staff was immediately contacted and recommended (R1) be given PRN medication for pain and/or anxiety. A non-emergency medical transport company arrived and assessed (R1) and determined with the hospice company to take (R1) out for further medical evaluation. The facility was contacted by the hospital physician on 1/21/26 (5:48 am) to confirm (R1) had a fracture on their right side hip. The RCC indicated (R1) had a partial hip surgery also on 1/21/26 and hospice has been coordinating with the hospital since then regarding (R1) transferring to a skilled nursing facility. The RCC stated (R1) regularly uses a walker and staff will always monitor them. The RCC confirmed with care staff that (R1) does get up at night, regularly, on their own to use the toilet, and has not fallen before, in over a year. It is not clear how (R1) fell, but when (R1) returns, they will be placed on 48 hour alert charting and have the NOC staff proactively assist with toileting breaks. It appears this was an isolated incident and staff responded in contacting hospice and outside medical attention. There are no deficiencies issued in this report. Exit interview. Copy of report provided to RCC.