Incident investigation·November 3, 2025

On 11-3-25 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Tracy Lehner, Memory Care director Waniesha Ortiz and explained the reason for the visit. The department is following up on a Death Report/Incident Report (IR) submitted by the facility on 10-29-25. LPA requested the following documents: discharge paper work, emergency room visit, MAR, admission agreement, care plan, progress notes and alert charting records. Staff reported the resident moved to memory care 10-20-25. Staff reported on 10-22-25 a family member took the resident to have teeth removed/oral surgery. Family brought the resident back to the facility after the surgery. Staff reported on 10-28-25 the resident had a fall at 3:00am and was sent out to the hospital. Staff reported the resident was returned to the facility about 10am on 10-28-25 with a fracture to left arm by her humerus. It was reported the resident was to wear a sling at all times to allow the bone to heal. It was reported on the discharge paperwork the resident was discharged to a Skilled Nursing Facility (SNF). Administrator will send a copy of the coroners report to LPA Benson. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report was given to Administrator.