Incident investigation·April 7, 2025

On 04/07/2025 at 2:04 PM Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 03/15/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated that the Resident 1 (R1) had an unwitnessed fall and after visit report indicated that the resident sustained closed compression fracture. LPAs reviewed the After Visit Summary dated 03/14/2025. The After Visit Summary indicated that there is no evidence of spine fracture and is due to age indeterminate. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.