Incident investigation·July 8, 2025

On July 8, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced case management visit at the above facility. LPA met with House Manager Heidi Seja who called the Administrator DeAngela Santos who arrived shortly thereafter. The death report indicates R1 (see attached confidential names list attached) passed away on 6/28/2025 after being transported to a the hospital with a spinal cord injury after an un-witnessed fall. R1 subsequently died at the hospital. The purpose of today's visit is to obtain medical documentation regarding R1. LPA left with a copy R1's medical file and pertinent information. Below is a statement from Administrator: Resident had mental disabilities, this was not anticipated. She was oriented to her environment, the bathroom is free of any hazards and well lit. Everything in our control was done and the whole situation has really impacted staff. Last year in March of 2024, it was noticed one day she had been drooling - refused to go to emergency room. Was vendored through CVRC- she was not obligated to go. We had wanted a referral to a neurologist. She had a history of seizures 20 years ago but was not actively seizing. The purpose of the visit was to rule out behavioral vs neuro. The day it occurred....R1 ambulates independently- she is continent and after she went into the restroom staff heard a noise and found her on the ground. She was conscious..no blood no bruising no obvious deformities of any limbs. She was on her back face , coherent and taking. Complained of her shoulder hurting (previous shoulder injury). Staff did not move her and called an ambulance. ER took R1 for shoulder x-ray and hen took her for a CT. The hospital put a C collar on her and did a central line and then put her on meds to raise her blood pressure and transferred to ICU. She passed away on the 28th and had been taken to the hospital the morning of the 26th.