Incident investigation·June 4, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Administrator, Danny Torgersen and Director of Nursing (DON), Karen Padilla. LPA stated the reason for the inspection was to discuss an incident report submitted to the Department on June 3, 2026, for resident (R1). There are currently (75) residents, (13) of whom are under hospice care. LPA discussed the incident where (R1) had an unwitnessed fall in their room on June 1, 2026. The DON stated she observed (R1) after the fall and their shoes nearby, and explained it appeared (R1) tripped on their shoes, which were open-backed. (R1) was sent to the emergency room following the fall and had surgery for a right hip femoral neck fracture. (R1) was also diagnosed with a Urinary Tract Infection (UTI), will be starting Physical Therapy, and may go to a skilled nursing rehabilitation facility for recovery and pain management. The DON stated (R1) moved in and was able to walk without a walker/cane. The Physician's Report (February 2026) notes (R1) is ambulatory. The Pre-Appraisal (May 2026) notes (R1) is ambulatory with a walker, does not have a visual impairment, and would regularly ambulate fine without a walker. Also discussed were updates on several residents, including those who recently had a UTI, changes in medications, or showed agitation. LPA asked that managers ensure staff are providing regular hydration to residents and offer water and cranberry juice. The DON stated staff regularly offer liquids and Popsicles to residents and will continue doing so. LPA suggested a staff refresher training be conducted to ensure residents remain hydrated during these upcoming summer months. This training was previously for today. It appears the facility sent (R1) out timely for medical intervention after their fall. There are no deficiencies issued in this report. Exit interview. Copy of report provided.