Facility Evaluation Report

12/03/2025 02:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Nora Serrano. Today’s visit is regarding an incident that occurred on 10/19/2024. On 11/25/2024 LPA conducted a case management regarding this incident and it was determined that additional information was required to determine findings.

It was reported that on 10/19/2024 3:00pm, staff heard what sounded like someone falling onto the floor in the hallway. Staff went to check and discovered Client 1 (C1) on the floor outside of the bathroom. Staff asked if C1 wanted to go to the emergency room and C1 refused. On 10/20/2024 C1 was able to walk and get into the van, and C1 did not appear to be in any pain. Staff had not noticed any bruises or swelling at the time. 10/21/2024 staff noticed that C1 appeared weaker since the fall. Staff again asked C1 if he wanted to go to the emergency room and he refused. Staff asked if he wanted some Tylenol and he said yes. C1 didn't say they were in pain. C1 was scheduled to see their primary doctor on 10/31/2024 at 8:30am.

LPA was notified by another source that C1 was diagnosed with a fracture as a result of the fall. LPA did not receive any updated incident report for this incident reporting that C1 had sustained a fracture.

Administrator stated that on 10/23/2024 they took C1 to the ER to be examined and they took x-rays during that visit. On 10/29/24 the administrator took C1 for a follow up appointment with the orthopedist to read the results of the x-rays. The orthopedist stated that there was no injury to C1 as a result of the fall and released C1 to return to work the following day.

LPA requested and reviewed the documents from orthopedist. On 10/19/2024 Patient was referred for left hip injury. Patient was seen in the ER where x-rays were obtained. 10/23/2024 Orthopedic surgery consult. Reason for request: Avulsion fracture greater trochanter, left. Diagnostics: x-rays reviewed left hip: Chronic irregularity of the greater trochanter with old avulsion fracture in good position. Assessment: Old avulsion fracture. Plan: Patient may return back to work. Weight bearing as tolerated. Conservative care. No surgical intervention is recommended at this time. Findings: No pelvic or hip fracture.

No deficiencies were cited as a result of the investigation. An exit interview was conducted and a copy of the report was provided to administrator Nora Serrano.