Incident investigation·May 1, 2024

Licensing Program Analyst (LPA), Daniel Pena, conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose to Wellness Director, Maria Moellman. Liz Najera, Administrator, later joined LPA and was briefed on the visit. Today's visit was in response to an Incident Report submitted to the Department, for Resident 1 (R1). Per facility reporting, R1 sustained a fall on 04/06/2024 which resulted in two (2) spinal fractures. Reports indicate R1 was transported to the hospital and underwent surgery. Per Ms. Moellman, R1 was transferred to a rehabilitation facility after hospitalization and the facility is awaiting notice as to whether R1 will return to the community. LPA conducted a review of R1's pertinent records and interviewed staff. No health and safety concerns were identified and no deficiencies were cited during today's visit. An exit interview was conducted with Administrator Najera, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.