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 Jacob Stevens and Nurse Susan Mosby and explained the reason for the visit. The department followed up on Incident Report (IR) sent by facility on 06-17-25 stating that resident, R1 had a fractured right femur which was diagnosed on 06/16/25. Staff reported finding R1 on the ground at 5:45am on 6-16-25 in front of recliner. Staff assisted R1 back into recliner. Staff reported that R1 spent most of the day in room in recliner. Staff reported they were unable to assist R1 out of recliner as R1 because of R1’s pain. Staff reported at 15:15 on 6-16-25 finding R1 on the ground in front of recliner again. Staff reassessed R1 at 3:30pm. Staff reported sending R1 to the hospital. R1's doctor ordered lab work and X-RAY with results of fractured right femur. Department conducted interviews with the administrator and Nurse director regarding this incident. At this time, this case is under review and the 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.