Incident investigation·July 15, 2025

On 07/15/2025 at 10:35 AM, Licensing Program Analysts (LPAs) Y. Brown and J.Clancy-Czuleger arrived unannounced to conduct a Case Management Inspection to follow up on an incident report that LPA Y. Brown received on 7/15/2025. LPAs met with facility staff and they called the Administrator. Administrator Mariano Alatorre arrived to the facility at 10:57 AM and LPA's explained the reason for the visit. The LPAs requested the resident (R1) records for review. LPAs reviewed and obtained a copy of R1's physician's report, after-visit summary notes from Eden Hospital, and R1's current and updated Appraisal needs and services plan. LPAs interviewed Administrator (AD) and discussed that R1 has a history of falls and there have been multiple incident of falls in the past at the facility none resulting in injury. AD stated that on 07/2/2025, R1 complained of pain on their right leg at night time. AD stated that R1 was experiencing cramps on their left leg and after consulting with R1's responsible party the facility staff gave R1 Tylenol. AD stated that the facility staff did not observe any swelling on the leg. AD stated on 7/3/2025, R1 continued having pain in their left leg and at around 11:34 AM, facility staff called Royal Ambulance for a non-emergency transport to Eden Hospital. AD stated that the facility staff did not see any swelling on R1's leg at this time either. AD stated that R1's daughter contacted the facility on 7/4/2025 and stated that R1 was getting discharged and that R1 obtained a small Tibula fracture. Continued on LIC809C. Continued from LIC809. AD stated that they believe the fracture could have occurred during transferring R1 on the hoyer lift. AD stated they have contacted R1's daughter and have been brainstorming different fall prevention ideas to help R1. AD stated that they are updating R1's Appraisal Needs and Services Plan to reflect R1's needs. During the visit, LPAs collected corrections of deficiencies from a case management visit on 6/19/2025 including S1's administrator certificate. LPAs also discussed the current status in the facilities CPU permit and the predicted timeline. LPAs may return at a later date. Exit interview conducted with Mariano Alatorre. A copy of this report provided.