Incident investigation·August 18, 2025

On 08/18/2025 at 11:40 AM, Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/17/2025. LPAs met with Health Services Director, Brenda Silva and General Manager, Ryan Turner, and explained the purpose of the visit. 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 had sustained a femur fracture. LPAs reviewed the following documents such as R1's Physician's Report, Individualized Service Assessment Plan dated 05/01/2025, 07/21/2025, 08/07/2025, and 08/18/2025, Facility Call Button Log, and After Visit Summary. Interview with Health Services Director stated that the resident was independent and Individualized Service Assessment dated 05/01/2025 stated that R1 will use their pendant to call on staff if assistance is needed. LPAs attempted to interview R1, however, R1 was unavailable during the the time. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.