Facility Evaluation Report

On 12/15/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Generations Program Director .

On 12/12/25, the department received an incident report of a fall by R1. The report stated that R1 had an unwitnessed fall on 12/8/25. LPA reviewed the internal incident report made by the responding med tech (S1). The med techs report noted R1 some have some minor pain and R1 stated they did not wish to have a medical assessment.

Med tech failed to follow program policy to notify emergency responders for an unwitnessed fall with report of pain. Med tech also failed to notify management of the fall.

On 12/10/25, the incident was reviewed by management and R1 was assessed further by facility staff. On 12/10/25 R1 was found to express pain with coughing and deep breathing. R1 continued to express resistance to medical care.

On 12/11/25, a family member brought R1 to urgent care where it was found that R1 had a rib fracture.

R1 did not experience significant loss of function or other health risk.

Therefore, facility staff did not notify 9-1-1, or management and this resulted in a delay in care to R1's injury.

The responding med tech is currently removed from that role pending further training.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. with Rena Gabriel. Copy of report and appeal rights provided