Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Terry Bechtold, Executive Director (ED) & (HSD) Health Services Director, Tosha Chowdory. The purpose of the visit was to follow up on two self-report incidents submitted to Community Care Licensing (CCL).

On 12/26/25 the department received the first incident report notifying about resident (R1) who on 12/20/25 was admitted to the hospital after their responsible party transported them to the hospital for further evaluation due to pain. On 1/27/26 a second incident report was received at CCL reporting that on 1/22/26 R1 was found on the toilet of their bathroom shaking, vomiting and screaming in pain. Staff called 911 and paramedics arrived, R1 was given pain medication through IV and they transported R1 to the emergency room for further evaluation. Responsible parties were notified. Per incident report, R1 had some imaging and testing done, which indicated a diagnosis of uncontrolled pain secondary to fractured hip, then R1 had surgery on 1/23/26 to repair their hip. Upon discharge from the hospital, R1 will have to go to a skilled nursing for rehabilitation.

During today's visit, LPA learned through a conversation with HSD and ED that R1 had a fall outside of the community back in December while walking with their private companion. At that time, there were no complaints of pain until days later, R1 complained of pain in their hip, and their physician was waiting on an opening to schedule a surgery.