Incident investigation·April 28, 2025

On 4/28/2025 Licensing Program Analyst (LPA) M. Garza completed an case management visit. LPA met with Administrator, Alex Zanin, explained reason for visit and was permitted entry into the facility. LPA toured facility and completed a health and safety check on residents in care. Residents were observed in common areas and in rooms. This case management visit is being conducted for incident reports that were received by the Department that required additional information. LPA requested and reviewed residents files (physicians reports, needs and services plans, reappraisals, hospital discharge paperwork, special incident reports (SIR) and logging notes) for R1, R2, R3, R4 and R5. Incident 1:The Department received an SIR for an incident that occurred on 1/8/25 for R1. During a shower R1 fell out of the shower chair and was complaining of right should pain. R1 was sent to the hospital and upon discharge was sent to Skilled Nursing Facility with a broken clavicle. Per SIR, R1 had UTI and possible pneumonia. File review of charting notes did not disclose any previous indications of change in condition. No deficiency cited for this incident. Incident 2: The Department received an SIR for R2 for an incident that occurred on 2/21/25. Staff completed a 6am check on R2 and found them not feeling well. EMS was contacted and R2 was transferred to the hospital. Resident was treated for the flu. File review of charting notes disclosed on 2/14/25 R2 had a fall. On 2/13/25 it is noted R2 is "a bit off". On 2/15/25 it is noted R2 "not felling well". From 2/3/25-2/21/25 there were other residents ill. No SIR's received for illnesses by the Department. Deficiency cited per Title 22. CONT... CONT... Incident 3: The Department received an SIR for an incident that occurred on 3/6/25 for R3. R3 had a fall bumping their head on the dresser. R3 obtained a 2 cm laceration to the right side of their head. EMS was contacted and transported R3 to the hospital. File review completed. Physicians report dated 12/18/24 states R3 requires assistance with all ADL's and requires some supervision. Review of hospital discharge stated R3 has small abrasion on scalp and can walk with assist and walker. Deficiency cited per Title 22. Incident 4: The Department received an SIR for an incident that occurred on 4/10/2025. R4 had an un-witnessed fall hitting the back of their head and complaining of left shoulder pain. EMS was called and R4 was transported to the hospital. Resident file reviewed. Functional Capability Assessment (not dated). Physicians report dated 3/10/25 states R4 has motor impairment/paralysis with no diagnosis listed. R4 is on 2 hour checks, will sometimes assist with transferring and to the restroom. No deficiency cited. Incident 5: The Department received an SIR for an incident that occurred on 4/16/25. During a shower R5 became pail, unresponsive, drooling and shaking. EMS was contacted and transported R5 to the hospital. Discharge paperwork stated dx of syncope and a follow up with PCP in 1 week. Follow up with neurologist is scheduled for 4/29/25 and an additional appointment with the cardiologist on 8/14/25. No deficiency cited. Exit interview completed with Administrator, Alex. A copy of this report, deficiencies and appeal rights provided.