Incident investigation·September 12, 2024

On 09/12/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced case management visit for an incident reported. LPA met with Executive Director, Judith Uy-Villaruz, and Health Service Director, Angelie Pasa, and the purpose of today’s visit was explained. LPA conducted a case management due to two Special Incident Reports (SIR) regarding resident falls submitted to Community Care Licensing (CCL) on 08/30/24. Resident R1 experienced a fall on 08/25/24 resulting in an injury requiring stitches. Resident R2 experienced a fall on 08/26/24 resulting in a fracture requiring surgery. During today’s visit, LPA toured the facility, checked all hallways, walkways, common rooms, and resident R1 and R2 rooms. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common rooms and Resident R1 and R2’s room was observed clean, clear, and free of hazards. LPA reviewed resident R1’s Physician’s Report, Needs and Service Plan (updated 06/30/24), Care Assessment, Fall Risk Assessment, hospital discharge paperwork, Internal Incident Report, and Progress Notes. LPA observed R1 has no history of falls and there have been no indications of being a fall risk. LPA reviewed resident R2’s Physician’s Report, Resident Care Assessment (updated on 06/07/24), Fall Risk Assessment, and Internal Incident Report. LPA observed R2 is completely independent and does not require any assistance. R2 has not experienced any falls in the past. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Judith Uy-Villaruz, Health Service Director, Angelie Pasa, and a copy of this report was provided.