Incident investigation·June 5, 2025

On 06/05/2025 at 2:25PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Director of Health and Wellness, Judith Gitonga, self-reported the incident on 06/02/2025. LPA met with Judith Gitonga and explained the purpose of the visit. LPA P.Manalo received a self-reported incident report from facility that indicated that the Resident 1 (R1) was taken to the hospital for upper leg pain from an unwitnessed fall on 05/29/2025. R1 was treated for a hip fracture. R1 had hip surgery on 05/30/2025 and is in a skilled nursing for recovery. The facility will reassess R1 before returning to the facility. During the visit, LPA reviewed and obtained R1's Physician's Report, Emergency ID Contact Information, Admission Agreement, Service Plan, and the facility's Fall Reduction Program. Admission Agreement showed that the resident was recently admitted to the facility on 05/26/2025. Prior to the resident's fall, the resident was already placed as a fall risk on the service plan for having multiple falls in the last 3 months. However, R1's Physician's Report dated on 05/05/2025 showed that the resident is bedridden. Since R1 is new to the facility, R1 was placed on an hourly check in. LPA may return at a later time. No deficiencies cited during visit. Exit interview was conducted with Director of Health and Wellness and a copy of this report was provided.