Incident investigation·July 1, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Marguerite Guerrero, Business Office Director and Mike Talani, Administrator, and explained purpose of inspection. The purpose of this case management inspection is to gather documents from a resident's file (R5) who unexpectedly passed in May 2025 and to discuss the following recent incident reports submitted on June 25, 2025. Resident (R1) had an unwitnessed fall on June 23, 25 (9:25 pm) while trying to grab a soda from the refrigerator. Resident sustained a bump on their head and was evaluated by Emergency Medical Technician's (EMT's). Resident refused to go to the emergency room when being evaluated, so the EMT's spoke with resident's family member after determining resident seemed to be fine. Resident was monitored and is doing fine and has not fallen again. Resident is not prone to falls. Resident (R2) had an unwitnessed fall on June 22, 2025 (3:48 am) and was found face down next to their bed. Resident was sent out for further medical evaluation and returned the same day with no new orders. A telephone appointment with the physician occurred on June 26, 2025. Resident will continue with Physical Therapy services and be administered pain medication as needed. Resident recently moved to Memory Care prior to the fall. Resident's care plan was updated recently and staff is proactively toileting resident more during the night to help prevent future falls. Resident (R3) had an unwitnessed fall on June 23, 2025 (4:30 pm) on the outside patio. Resident was sent out for further medical evaluation due to sustaining two skin tears on one arm and complaining of lower back pain. Resident returned the same day with no new orders. Resident will continue with Physical Therapy and Occupational Therapy and begin Home Health for wound care. Resident is doing fine currently. *cont on 809C-1.. 809C-1.. Resident (R4) was sent to the emergency room on June 17, 2025 due to their right ankle bleeding and blood pressure dropping. Resident returned the same day with a diagnosis of a hemorrhage and no new orders. Follow up appointments were scheduled with the physician (3) days later, in person, and by video in July. Resident currently takes blood thinners so bleeds easily. Resident is wearing a different kind of footwear that is more cushiony to help with thinning skin. The facility administrator stated there are Physical Therapy and Occupational Therapy services on site, and they are offered to all residents who have had a fall. Additionally, every fall is monitored and logged and discussed weekly with Assisted Living and Memory Care managers. The Administrator stated each fall is analyzed for the cause and what interventions have been implemented. The facility responded quickly and appropriately to each resident fall. There are no citations issued in this report. Exit interview. Copy of report provided.