Incident investigation·December 30, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit. LPA Cortez met with Executive Director Andrea Davis at approximately 3:30 pm and explained the purpose of the visit. On 12/30/2025, Community Care Licensing Division (CCLD) received a self-reported LIC624 Unusual/Incident Report pertaining to Resident 1 (R1) who was reported to have broken their 6th and 7th rib. During today’s visit, LPA Cortez reviewed and obtained documents pertaining to the investigation and conducted in-person interviews with the ED, Care Director and R1. Staff interviews revealed that R1 is diagnosed with Dementia however, was not a fall risk prior to this incident, does not use a walker, and is able to walk on their own and independent. R1 was taken to the hospital and the hospital attributed the broken ribs to a possible fall, however no fall was reported by R1 or staff. To prevent future falls R1 is now being checked on hourly, is now considered a fall risk, and will be getting physical therapy with home health. Interview with R1 revealed that they were told they have two broken ribs and have a little bit of pain but do not remember any fall, staff treat them wonderful, they are able to walk on their own, do not require much care and has no concerns. Documents reviewed did not indicate R1 as a fall risk, and per their LIC602 dated 03/31/25, R1 was not deemed as disoriented, lack of hazard awareness, and was not deemed as unsafe wondering. During the visit the LPA did not observe any immediate health or safety concerns. If further investigation is warranted the LPA will return at a later date.No deficiencies noted during today’s visit. Exit interview conducted. Copy of report was issued.