Incident investigation·April 30, 2026

On April 30, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management - Incident visit. LPA met with Administrator and the Resident Care Director, Hola Finau and LPA explained the purpose of today's visit. On April 17, 2026, the facility reported an incident that happened on April 14. 2026 in which R1 was observed by staff #1 (S1) in bed, yelling due to severe pain. S1 assessed R1 and it was noted that R1 could not stand and both legs were swollen which resulted in staff calling 911. The incident report indicated that R1 was diagnosed with hip fracture and received left hip surgery and returned to the facility. The incident report did not include the cause of the hospitalization. During today's visit, LPA interviewed the Resident Service Director and R1. According to the Resident Service Director, on 4/13/2026, R1 was pushing the wheelchair while walking with the private caregiver and R1 lost balance and fell. The private caregiver reported it to the medication technician (med tech) who assessed R1 and did not notice any injuries at the time. However, on the next day, 4/14/2026, R1 had a change in health/physical condition that resulted in hospitalization. LPA interviewed R1 who remembered the fall and the hospital stay but no other details. Based on documents provided, LPA observed R1's Needs and Service Plan was updated interventions to reduce fall. No deficient is cited today. This report is reviewed and discussed with the administrator and a copy is provided.