Incident investigation·July 10, 2025

On 07/10/2025 at 1:05 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/03/2025. LPA met with Health Services Director, Brenda Silva, and explained the purpose of the visit. General Manager, Ryan Turner, gave authorization for Silva to sign the report. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary stated that the resident was treated for a closed hip fracture. During the visit, LPA reviewed R1's Physician's Report dated 01/30/2023 and 07/09/2025, Individualized Service Plan, Individualized Service Assessment, and After Visit Summary dated 07/10/2025. A review of R1's Physician Report revealed that R1 has a diagnosis of osteopenia. R1's Individualized Service Plan dated 06/21/2025 showed that R1 is independent with most Activities of Daily Living's (ADLS). LPA spoke with R1 during the visit. R1 stated that R1 lost their balance and fell on the ground. R1 stated that R1 fell on R1's hips. R1 stated that staff arrived shortly after to assist R1. No deficiencies issued during the visit and a copy of this report provided.