Facility Evaluation Report

05/28/2025 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding two incident reports that were submitted to licensing regarding incidents that occurred on 04/15/2025 and 05/22/2025. Both of these incidents resulted in residents sustaining fractures related to falls that occurred in the facility.

On 04/15/2025 Resident 1 (R1) pushed their PHB was complaining of left hip pain and wanted to go to the hospital to be checked out and get x rays. EMS was called and resident was transported to local hospital for evaluation. R1 was admitted to hospital with a diagnosis of hip pain and a fractured sacrum.

During the investigation it was learned that on 3/04/2025 R1 was walking their dog and fell. R1 was sent out to hospital for evaluation and sent back with pain medication. On 04/07/2025 R1 had bruising due to an unwitnessed fall and was sent out again with no findings. On 04/15/2025 R1 had unmanaged pain and was sent out to the hospital, and was diagnosed with fractured sacrum. R1 was still experiencing pain so the facility sent R1 back to the hospital and they were discharged with stronger pain meds, home health, and physical therapy referral.