Incident investigation·May 6, 2025

On 05/06/2025 at 2:15 PM, Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 04/29/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. Health Services Director self-reported multiple fall incidents that occured with Resident 1 (R1) on 04/25, 04/26, 04/27. LPAs interviews with Health Services Director indicated that R1 has a 1:1 caregiver from 10 PM to 6 AM daily. Record reviews shows that the facility updated R1's Service Plan and Individualized Service Assessment after the incident of the multiple falls. R1 has also moved to the Memory Care Unit and hasn't fallen since the implementation of the their new plan. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.