Follow-up·November 7, 2025

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on four self-incident report dated between 10/17/25 and 10/31/25 received by the department regarding falls and met with Patricia Gustin, Administrator. -On 10/17/25, incident received dated 10/12/25 staff noted about 1:00pm that resident (R1) was lying on the floor face down next to their bed. Apparently R1 was trying to walk using their walker and may have tripped over their own legs. R1 was observed confused and tearful, and complained of having pain in their head. Staff called 911 to transport R1 to the hospital for further evaluation, where they were diagnosed with a fractured hip. Responsible parties were notified. During today's visit, LPA learned that R1's responsible parties decided that R1 will be continuing to receive hospice services. -On 10/23/25, incident dated 10/18/25 reported that resident (R2) was observed by med-technician while walking by their residence at about 4:15pm when a "moaning" sound was heard coming from R2's apartment. Upon entering the apartment, R2 was noted to be standing in their living room and stated that they had fallen. There was a small cut noted above their right eyebrow, R2 was complaining of right knee pain and staff determined to call 911 to transport R2 for further evaluation, where they were diagnosed with bacterial urinary tract infection and closed non-displaced fracture of the right patella. Responsible parties were notified. Based on records review of R2's care plan dated 6/18/25 did not have any updates, because there were no change of condition to increase level of care. Continue on LIC809C... Continued from LIC809... The last two incident reports received on 10/23/25 and 10/31/25 30/25 involving resident (R3) regarding two falls. The first fall occurred on 10/21/25 at about 4:30pm, R3 pressed their pendant to alert staff about their fall from their wheelchair after "fallen asleep" and complained about head and back pain, the med-technician called 911 to transport R3 for further evaluation, resident's responsible parties were notified, imaging tests indicated that there were no injuries and R3 returned to the facility same day with no new orders. On 10/28/25 at about 10:20pm, R2 pressed their pendant after falling on their back in their kitchen. After staff assessed R3, it was determined to call 911 due to R3 was complaining of pain in their left hip, R3 was taken to the emergency room for further evaluation. Responsible parties were notified. Today, LPA was informed that R3 was diagnosed with hip fracture and they had surgery. The facility is currently in the process of obtaining updated physician report to update their care plan prior to R3's discharge back to the facility. No citations were issued during today's visit. Exit interview conducted with Administrator and copy of this report was given.