Incident investigation·February 19, 2025

At approximately 1:55PM, Licensing Program Analysts (LPAs) Loera and Stevenson arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Cris Cardenas. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL) on 01/30/2025. The incident report states that Resident 1 (R1) fell from their bed. Staff immediately called 911 and R1 was transported to the hospital and then transported to a rehab center. Per conversation with Administrator and document review, R1s responsible party discharged R1 against medical advice from the rehab center and was returned to facility on 02/01/2025. Per conversation with Administrator, facility has instituted a fall prevention plan with a motion detector in front R1s bed and has night time staff posted outside of R1s bedroom for supervision. LPAs requested for facility to send in writing of updated care plan. Per review of R1s diagnosis, R1 has a history of falls. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.