Incident investigation·September 10, 2025

On 9/10/2025 at 3:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 8/30/2025. LPA met with General Manager, Michael Fillari and informed him the reason for the visit. Based on the incident report received on 8/30/2025, resident (R1) was heard calling for help from the apartment and S2 observed R1 on the floor. R1 stated she lost her balance and fell while in the middle of dressing. S2 called 911 and notified R1's family. R1 was diagnosed with a fractured femur and some broken ribs. During visit, LPA reviewed R1's file and observed R1 was independent for majority of ADL care. R1 needed some assistance with care. LPA interviewed S2 and was informed R1 had an unwitnessed fall. R1 is current at a Rehabilitation Center. S2 stated R1 will be re-assessed upon returning to the facility. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.