Incident investigation·April 18, 2025

On 04/18/2025 at 10:05 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct a case management visit regarding an incident that happened on 04/07/2025. LPA met with Roseline Prasad, Executive Director and explained the purpose of the visit. LPA received a special incident report regarding an altercation between R1 and R2 that resulted in R1's hip fracture. ED stated that the incident happened during shift change on 04/07/2025 at 2:30 PM. R1 was transported to hospital and was admitted for hip fracture. LPA spoke with Executive Director and the Resident Care Coordinator (S1) , and reviewed the incident report with them. LPA also toured R1 and R2's rooms. Both residents were in their rooms. LPA requested and reviewed the following documents during the visit: R1 and R2's Physician reports, care plans, Interdisciplinary progress notes for both residents, Staff schedule for 04/2025, Shift schedule, and doctors reports related to the incident. LPA's Review of the progress notes revealed that the responsible parties were called and notified regarding the incident. LPA also interviewed ED who stated that there is a regular check-ins scheduled for R1 and R2 every 15 minutes. ED stated that there is a log that documents the check-ins completed by the caregivers. LPA reviewed the log during the visit. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.