Facility Evaluation Report

On 5/4/26, LPA K. Nguyen conducted case management based on files reviewed, which showed that the incident for R1 occurred on 4/18/26 and was reported on 4/26/26, within the 7-day requirement during a complaint visit (15-AS-20260427163254).

The interview showed that R1 was not admitted to the hospital due to R1's refusal; however, the facility has an on-site nurse who conducted an evaluation after the fall and noted that there was no serious injury at the time of the fall.

LPA requested that Ed review 87211 Reporting Requirements and submitted a self-certified letter of understanding regarding the regulation mentioned above, including protocol of facility reporting requirement and submit to CCLD by the POC date of 5/8/26.

Exit interview conducted and a copy of this report provided via email.