Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 02/19/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 02/12/2025 indicated Resident 1 (R1) was sent out for elevated heart rate, lethargy and increased respirations. Incident report notated at the bottom that resident had sustained a displaced fracture of medial condyle to the right tibia. Interview with facility indicated the report inadvertently referred to a fracture that occurred previously in December 2024. In December 2024, R1 had an un-witnessed fall near the front door of the resident room. Resident stated at the time attempting to get to the restroom and got dizzy. At the time of the incident R1 was able to leave the facility unassisted and independent of activities of daily living. However, primary diagnosis per physician report is difficulty walking. Care plan dated 10/08/2024 indicated fall precautions encouraged such as low bed and scoop mattress which LPA observed during the visit. Resident had no prior falls.

Exit interview conducted and a copy of this report was left at the facility.