Incident investigation·May 12, 2025

On 05/12/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management visit to the facility listed above. LPA met with Executive Director, Judith Uy, and the purpose of today’s visit was explained. LPA was granted entry into the facility. LPA conducted a Case Management visit to follow-up on an incident report that was submitted to the department on 05/01/2025 for three (3) different residents. Resident R1 had an unwitnessed fall in their room on 04/27/2025. The fall resulted in R1 being diagnosed with inferior pubic ramus fracture, not requiring surgery. Resident R2 had an unwitnessed fall in the hallway near the dining room. The fall resulted in R2 being diagnosed with right rib fracture, not requiring surgery. Resident R3 woke up with severe back pain and requested to be seen by the doctor. R3 was diagnosed with a Thoracic Vertebral Fracture, no surgery is required. During today’s visit, LPA inspected the facility, interviewed Residents R1-R3, and received and reviewed documents pertinent to the visit. LPA reviewed Resident’s R1-R3 Physician’s Report, Individualized Service Plan, Preplacement Appraisal Information, Assessments, and In-Service Logs for Fall Management Protocol dated 05/07/2025. During the facility inspection, LPA observed all walkways and hallways throughout the facility to be clean, clear, and free of obstruction, and/or hazards. In the resident rooms, LPA observed the rooms of Resident R1, R2, and R3’s rooms were clean. All walkways were observed clean and clear. During an interview with Resident R1 stated they just lost their balance and fell. During an interview with Resident R2 stated they tripped over their own feet while walking and fell. During an interview with Resident R3, stated the fracture can happen with the type of medical condition they have and that the did not experience a fall. During today’s visit, LPA did not observe or cite any deficiencies. LPA did not observe any Health or Safety concerns. An exit interview was conducted with Executive Director, Judith Uy, and a copy of this report was provided.