Incident investigation·April 24, 2025

On April 24, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced case management visit at the facility. LPA met with House Manager and also conducted a phone conference with Administrator Paulette Holland to discuss the purpose of the visit. LPA explained there were two recent incident reports that were lacking a bit of information see explanation below: 1- Resident 1 - date of occurrence 4/6/2025. R1 was found in bathroom after a fall. Staff helped her up did a quick exam to check for injuries only noticed a small amount of redness on elbow. R1 was offered an ice pack and there was no need for further care. LPA explained that the IR should have included information as to why R1 fell and what will happen as a result . For instance was this the first time, is she a fall risk, was the family notified, will we closely monitor. Although the staff did the right thing, the report needed further description. 2. Resident 2- date of occurrence 4/5/2025- R2 was found in bed shaking with his eyes rolled back. Staff called house manager and 911. R2 was taken to Clovis community Hospital. The report was lacking information regarding what was the diagnosis, any change in care plan, any follow up needed. Administrator and house manager understood the reports could have included more information and will ensure that going forward there are more complete. LPA requested to have staff continue to send reports to the incident fax line and to also send them directly to LPA for review through email. A copy of this report was left with Felicia Sanchez.