Incident investigation·July 29, 2025

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to follow-up on Unusual Incident Reports received in our Regional Office. LPA was greeted and granted entry into Villagio by the Concierge and met with Memory Care Director (MCD) Marisa Hernandez. The following documents were obtained and reviewed: Resident #1 (R1)'s Facesheet, Physician's Report dated 1/24/2025, Individualized Service Plan (ISP) dated 7/24/2025, Resident Assessment, Pre-appraisal Assessment and Hospice Plan of Care dated 7/18/2025. LPA interviewed two of two staff and Resident #1 (R1)'s Responsible Party. On July 2, 2025 R1 had an unwitnessed fall and was transported to the hospital for further evaluation. There were no medical issues noted at this time. On July 4, 2025 R1 had an unwitnessed fall in the community hallway. R1 was transported to the hospital and was diagnosed with a broken nose. R1 returned to the community and for four days family members remained at the community with R1 due to R1 trying to remove nasal tubes. On July 11, 2025 a 1:1 private caregiver was hired to remain with R1 and to help with tube removal behaviors. On July 18, 2025 R1 began receiving hospice services. On July 24, 2025 a care plan meeting was held with family regarding R1's change of condition and a new ISP was signed on 7/24/2025. On July 28, 2025 R1 was leaving the community with a family member for an outing when R1 fell. R1 was sent out to the hospital and was diagnosed with a hip fracture. (Continued on LIC 809-C) (Continued from LIC 809) LPA spoke with Responsible Party who stated they were happy with the care being provided to Resident #1 and that there are no issues at this time. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Marisa Hernandez, Memory Care Director and a copy of the report and files reviewed (LIC 811) were given at the time of the visit.