Incident investigation·August 18, 2025

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit to follow up on a Special Incident Report (SIR) received on 7/30/25. LPA met with Jacqueline Cortez, Executive Director and explained the reason for the visit. Per SIR, Resident 1 (R1) was found in their room on the floor and was observed to be disoriented on 7/28/25. Staff made a 911 call and R1 was transported to the hospital for further treatment and evaluation. SIR also indicated, R1 was displaying signs of possible accidental overdose when found in their room. During today's visit LPA interviewed Executive Director (Staff 1/S1) who stated, R1 was transported to the hospital due to displaying signs of possible accidental overdose from mismanaging their medication. At the hospital, R1 was treated for possible overdose and was released to a skilled nursing facility due to the incident. S1 further stated, R1 will no longer be coming back to the facility due to R1 requiring a higher level of care. Interviews with Wellness Director and med-tech staff 1 (S1) indicated, R1 was managing their own medication and R1 had never experienced a medical emergency like the one experienced on 7/28/25. Review of R1's Clinical Requisition/Physician's Orders documentation indicated, R1 was able to self-administer medication. LPA toured common areas of the facility and no immediate health and safety concerns were observed during time of visit. No deficiencies noted during today's visit. Exit interview held with Jacqueline Cortez and a copy of the report was provided to the facility.