Incident investigation·July 8, 2025

On July 8, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow-up on an incident that was reported by the facility. LPA met with the interim administrator, Rowena Cancino and explained the purpose of today's visit. On 7/1/2025, the facility reported resident #1 (R1) had an unwitnessed fall in the bathroom and sustained a laceration of scalp. R1 was sent to the hospital and returned a few hours later. The interim administrator stated that R1's family member was in the room during the fall and alerted staff of the fall. During today's visit, LPA observed R1 in the room, appeared to be comfortable and pleasant. R1 did not remember the fall and stated that she was not in pain. According to the interim administrator, as part of the fall management program, the facility has implemented status checks for R1 every 2 hours, R1 is receiving Physical Therapy from a home health agency and R1 has not sustained any further falls. The interim administrator stated that the facility will conduct another fall assessment for R1 in a few weeks. No deficient is cited today. This report is reviewed and discussed with the interim administrator. A copy of the report is provided.