Incident investigation·May 20, 2026

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 20, 2026 to conduct a case management visit on an incident which was reported to the Department on May 2, 2026. LPA met with interim Executive Director Desiree and explained the purpose of the visit. LPA and Desiree discussed R1's incident on 4/24/2026. R1 had a fall on 4/17/2026. This fall occurred because another resident opened a door, which caused R1 to fall. 911 was called and R1 was sent to Sutter ER for evaluation. ER discharged R1 with a diagnosis of injury of right shoulder, initial encounter. Xrays were conducted and no signs of broken bones. On 4/23/2026, R1's primary physician arrived at facility and assessed R1. This primary physician said that R1 did not need to wear a shoulder sling and advised the facility to monitor the resident and give Tylenol as needed. On 4/24/2026, staff observed R1's right hand was swollen with complaints of severe pain. R1 was transported back to Sutter ER where they were diagnosed with a closed displaced fracture of the humeral neck at the right shoulder. R1 returned to the facility with instructions to make a follow-up appointment with an orthopedic surgeon. On 4/27/2026, Desiree called to follow-up with the orthopedics office to try and schedule an appointment. Family then decided to place R1 on hospice services. R1 was admitted to hospice services on 4/29/2026. LPA obtained a copy of R1's physicians report, care plan, hospital discharge paperwork. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.