Facility Evaluation Report

On 10/22/2025, around 09:30 AM, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Lavinia Muscan were present for an informal meeting with Administrator Chad Rogers, Regional VP of Operations Terry Ervin, Senior VP of Health Services Jennifer Sato, Senior Regulatory Director Kevin Wrigley, and Nurse Jimmy Duong, which was held via Teams.

During today's meeting, department discussed complaint history, including the complaint dated 09/25/2024. Facility representatives discussed the updated fall protocols for residents that are fall risks, such as:

-Having an extensive fall mitigation program in place including an in-house rehab partnership that have led to a reduction in the severity and frequency of falls that take place.

-Current Fall Risk Assessments and resident centered fall interventions on service plans for residents identified as fall risks. Ongoing team member training on identifying changes of condition related to fall risk and resident interventions.

-Policies are in place to ensure that residents who suffer multiple falls receive additional fall reduction measures. In those cases where fall mitigation measures are no longer effective, we have policies in place to aid residents/families that help determine a care setting that will best meet the residents’ fall care needs.

No deficiencies cited. Exit interview conducted. A copy of this report was provided to Administrator.