Incident investigation·June 5, 2025

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to follow up on two self-incident report dated 5/12/25 and 6/2/25. LPA met with Teresa Astudillo (Med-Technician). Licensee Alex Varshavsky was not able to come to the facility, but were available by phone and gave authorization to staff to sign the report. Per incident report, on 5/8/24 resident (R1) was observed limping and their left leg appeared swelling, staff notified their physician who instructed them to send R1 to the hospital for further evaluation, where they were diagnosed with mildly displaced patellar fracture with history of osteoporosis . R1 returned to the facility same day. Second incident report, On 5/27/25 resident (R2) was found on the floor, after attempting to transfer themselves from bed to the wheelchair. According to incident report, R2 did not call for assistance. Staff immediately called paramedics who assessed the fall, R2 was transported to the hospital for further evaluation, where they were treated for bone bruising and abrasions. Both responsible parties were notified. During today's visit, LPA have reviewed R1's & R2's physician report and care plans. After this incident, the facility have developed a plan of action including implementation of person centered care to meet their care needs. Also, LPA confirmed that the call alert system was working properly, which it has been an area of concern previously discussed with the Licensee. After pulling the call button for help, LPA heard a sound beep in the office and staff was alerted, who arrived timely to assist resident in the room. LPA observed paper products available in bathrooms used by residents including toilet paper and paper towels. No deficiencies cited during today's visit. Exit interview was conducted with Med-Tech and a copy of this report was given.