Facility Evaluation Report

03/03/2026 09:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with staff Jeanine Pulomones. LPA spoke with licensee Serina Bortz by telephone during the visit. Today’s visit is regarding an incident that occurred on 01/19/2026 and was reported to licensing on 01/20/2026.

It was reported that on 01/19/2026 11:30 PM facility staff heard a loud banging sound coming from Client 1’s (C1) room. Staff went to check on C1 and found C1 on the floor half dressed. C1 told staff they had a bladder accident and was changing into clean clothes when C1 lost their balance and fell.

Facility RN and administrator were notified. C1 complained of pain, requested over the counter pain medicine, and was given Ibuprofen according to their PRN sheet. No skin tears or bruising were found on C1. C1 refused to be taken to the ER.

The next day at 8:00 AM Staff 1 (S1) called facility RN and reported that C1's left shoulder was swollen. RN assessed the swelling and determined that C1 needed to go to the ER. C1 was taken to the Er by RN. X-rays of C1’s shoulder and arm were completed and it was determined that C1 had a fracture of their left humorous. Physician stated C1 had an old fracture that had not healed properly that contributed to this current fracture. Physician placed C1’s arm in a sling, gave orders for immobilization, and a referral to an orthopedic doctor. The hospital stated that surgery was not required for this fracture.

During the course of the investigation, it was learned that Client 1 is very independent, moves fast and in the past was reluctant to ask staff for help. C1 is now better about asking for help. C1 has been seeing an orthopedist for their injury and is currently undergoing physical therapy.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to licensee David Bortz.