Incident investigation·May 13, 2025

Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on a incident report that was received 01/06/25. LPA explained purpose of visit to Administrator. The incident report was regarding a resident's (R1) death. On 01/01/2025, Resident 1 (R1) sustained an unwitnessed fall in her apartment and was timely taken to San Joaquin General Hospital where they was diagnosed with a subdural hematoma. File review records indicate R1 was a fall risk when they moved into the facility in May 2024 due to a fall that was sustained prior to moving into Brookdale Lodi. Staff report that within months of moving into Brookdale Lodi, R1’S physical health improved, and they did not show any signs that would support they were a fall risk resident. R1 was independent and did not require frequent checks. Prior to the fall on 01/01/2025, R1 sustained one minor fall in June 2024, but it did not result in serious injury. No specific fall measures were put in place at that time as R1 was independent and did not show indicators of being a fall risk. This investigation concludes that there is insufficient evidence to support that the fall/injury was as a result of staff neglect/lack of care. Exit interview and copy of report given.