Incident investigation·July 16, 2025

On 07/16/2025 at 10:15 AM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit due to receiving a self report of an SOC341 of a resident's hygiene needs not being met and the lack of documentation of resident's change in condition. LPA met with Health and Wellness Director, Jeffery Jackson, and explained the purpose of the visit. During the visit, LPA observed Resident 1's (R1's) room having a strong smell of urine. However, LPA observed R1's mattress in clean linens and R1 in clean clothing in the dining hall. LPA interviewed Health and Wellness Director and 4 staff. LPA attempted to interview 3 other staff but was unavailable during today's visit. LPA reviewed and obtained R1's after visit summary, internal incident report, physician's report, personal service plan, prescription order, progress notes, third party collaboration notes, staff schedule, staff contact list, and SOC341. LPA may return at a later time. No deficiencies cited. Exit interview conducted and a copy of this report provided.