Incident investigation·November 7, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator. LPA stated that the reason for today's inspection was to follow up on an incident report submitted to the Department on October 30, 2025. The incident report relates to resident (R1)who was had an unwitnessed fall on October 29, 2025 (6:20 AM). The caregiver found (R1) lying down on the floor next to her bed. The shift manager was notified and checked (R1) who was found with blood dripping from their forehead. (R1) was sent out for further medical evaluation and returned the same day with no new orders but with a diagnosis of: ground level fall, laceration of forehead, and blunt head trauma. (R1) is not currently taking blood thinners but takes Depakote which can cause minor bleeding or bruises. (R1) has had multiple falls since moving in on/around June 2025. (R1) had a follow up appointment on October 30, 2025 (10:00 am). (R1) has a history of falling and has a walker but forgets to use it, so staff provides cuing. The care plan was updated October 30, 2025 to reflect additional assistance needed with transferring and cuing. On November 4, 2025, (R1) was evaluated given a Post Fall Assessment and evaluated using the Morse Fall Scale on November 4, 2025, which determined (R1) to be a "high fall risk". (R1) was moved to another resident room near better camera coverage and was monitored 4x per shift. LPA observed the prior room to have a night stand next to (R1's) bed and to have less natural lighting. LPA observed the new room to have a taller dresser and more natural lighting. LPA observed (R1) sitting in the dining area earlier today and to have extensive bruising in the process of healing from their forehead to their neck area. The facility will continue to monitor (R1), who will also go to medical appointments as needed. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.