Incident investigation·July 17, 2025

On 7-17-25 Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Angelina Mandria Skevig and explained the reason for the visit. Department followed up on Incident Report (IR) sent by facility on 06-23-25 stating that resident, R1 had a hip fracture which was diagnosed on 06/21/25. Staff reported hearing a noise inside the bathroom on 6-21-25 at 4:30am. Staff opened the door and found R1 lying on left side on the floor. R1 said their left knee gave out and they fell. Staff reported a penny size skin tear was peeling on elbow and complaining of pain in left hip. Staff reported sending R1 to the hospital. R1 doctor ordered lab work and X-RAY with results of hip fracture. Department conducted interviews with the administrator regarding this incident. At this time, this case is under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.