Incident investigation·September 17, 2025

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Resident Services Director, Jocelyn Vahle. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 07/07/2025. Report states on 07/04/2025 at approximately 5:30PM resident (R1) had a severe fall when visiting their home with a friend outside of the community. R1 had fell hitting their head. They called 911 and R1 was admitted to the hospital for further evaluation. Per conversation with Resident Services Director, R1 sustained a subdural hematoma and needed a Gastrostomy tube. R1 is no longer at facility as they required higher care. Incident Report 2: CCL received an incident report on 07/07/2025. Report states resident (R2) had an unwitnessed fall and was found on the floor besides their bed. Staff member helped R2 up and to the bathroom where she noticed a bruise on the side of her left eye. 911 was called, as well as R2s daughter, who suggested that R2 did not go to the hospital but to call hospice instead. Per conversation with Resident Services Director, R2s family refused for R2 to be transported to the emergency room. The hospice nurse came to check on R2 with no concerns. R2 is currently still on hospice. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Resident Services Director.