Incident investigation·March 20, 2024

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management - Incident visit to the this facility. Upon arrival LPA met with staff and reason for visit was explained. Staff contacted Administrator who arrived at approximately 4pm. Reason for the visit was discussed with the Administrator Kathiga V. The facility self-report an incident, noting that on 03/08/2024, resident #1 (R1) suffered a fall in the private room, which resulted in fractured hip and hospitalization. According to the staff, they heard noises from R1's room and found R1 sitting on the carpet. R1 reported to staff that they lost their balance. it was also noted that staff checked R1's body, found no bruises, but R1 was in pain so staff gave R1 pain medication and R1 went to bed. According to staff and Administrator R1 slept well through the night. However, in the morning, R1 complained of having pain, therefore Administrator called 911 and paramedics took R1 to Community Memorial Hospital. R1 sustained a fractured left hip and undergone surgery. During today's visit, LPA and staff toured the facility which consist of six (6) resident bedrooms, three (3) bathrooms, garage, and kitchen at approximately 3:15pm. Also during todays visit LPA conducted a file review at approximately 3:30pm and obtained pertinent documentation relating to R1. Interview with staff and Administrator was held regarding this incident at approximately 4pm. According to staff and Administrator R1 was not considered a fall risk; R1 was able to ambulate with a walker with no assistance. According to Administrator and staff no history of any other falls at the facility for R1 since date of admission 02/10/2018. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time. This case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation. Exit Interview Conducted and Report was Issued.