Incident investigation·November 10, 2022

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced case management visit due to an incident reported to Licensing on 11/3/2022. LPA met with the Administrator, Diana Medina, and explained the purpose of the visit. The incident report stated that on 11/1/22, Resident #1 (R-1) missed a step and fell in the Magnolia Court corridor. R-1 sustained a Le Fort 1 level fracture. Per the Administrator, R-1 is an independent resident who does not need any care services. Resident is able to ambulate on own and does not require any assistance with mobility. Based on the physician's report, R-1 is able to leave the facility unassisted and does not have any cognitive impairment. LPA spoke with R-1 during the visit today and R-1 stated he/she does not need assistance from staff. There is a phone or call string that can be used to contact staff if there is an emergency. R-1 stated that resident did not see the step, fell forward, and injured the mouth area. R-1's son was also present and confirmed that resident is independent. Interviews were also held with 2 LVNs who stated that for independent living residents, they have emergency lights/phone in their rooms. In the event there is an emergency, the nurses will tend to their calls immediately. As for R-1's current condition, they do health checks on every shift to monitor the resident. In addition, the Administrator stated that since this incident occurred and to prevent another injury, yellow strips were placed on the steps for more visibility. Based on the information gathered, there is no signs of neglect or lack of supervision found. No deficiency was issued. An exit interview was held and a copy of this report was provided to the Administrator.