Incident investigation·April 22, 2025

On 04/22/2025 at 2:20 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Executive Director self-reported the incident on 04/05/2025. LPAs met with Executive Director, Emily Poon, 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 lower back and rib area pain in which R1 was treated for lumbar fracture. LPAs reviewed the After Visit Summary dated 04/07/2025 and status update from doctor dated 04/10/2025. The status update from doctor shows that the fracture of vertebra was due to osteoporosis, sequela. No deficiencies cited during visit. Exit interview was conducted with Executive Director and a copy of this report was provided.