Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Assistant Executive Director Matia Grochowiak .

Community Care Licensing received an Incident Report on 6/19/26 in which it was reported that on 6/18/26, a Resident (identified as R1) was being assisted by a staff member with a transfer from their bed to their wheelchair when R1 experienced a sudden loss of leg strength and the staff member assisted the resident to the floor. A second staff member arrived and both assisted the resident from the floor to their wheelchair and the resident reported a dull pain to the right knee. About 30 minutes later staff conducted a follow up check with R1 and no pain was reported and R1 was observed to be participating in activities. Three hours later, the resident reported severe pain to their right knee and emergency services were contacted and R1 was taken to the hospital where a right femur fracture was discovered.

During today's visit, LPA conducted file review and consulted with Assistant Executive Director Grochowiak and Business Office Manager Recce about R1's care/supervision needs and the facility's plan moving forward. R1 was not in the community and is receiving services at a nearby SNF (Skilled Nursing Facility). Per review of R1's file, it was noted in both R1's assessment (dated for April 2026) and service plan (dated for May 2026) that R1 required a two (2) assist for all transfers. R1 is additionally labeled as a fall risk in their file. Per review of the incident report and staff charting notes, only one (1) staff member was present assisting R1 with a transfer at the time of incident.