Incident investigation·December 11, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection and met with Nekia Xavier, Health and Wellness Director, and Mike Talani, Administrator. LPA explained the purpose of the inspection was to deliver findings for an investigation the Department's Investigative Bureau (IB) conducted regarding the non-hospice death of (R1) in May 2025. During the course of the investigation, the Department interviewed multiple facility staff, residents and reviewed extensive documentation, including hospital medical records, facility physician's reports, care plans, the incident report (LIC624), and charting notes for (R1). The results of the investigation are as follows: Resident (R1) was found on the ground in their room on May 17, 2025, (0808 hours) during morning rounds, and appeared confused and complained of pain in their shoulders. Staff called 9-1-1 and resident was sent out for further medical treatment as having a possible stroke. (R1's) urinalysis revealed a possible infection and (R1) was admitted to the Intensive Care Unit (ICU) with a diagnosis of septic shock, secondary to Urinary Tract Infection (UTI). (R1) passed on May 17, 2025 (1937 hours), and their immediate cause of death is noted as septic shock , with an underlying cause of a Urinary Tract Infection (UTI). Multiple facility residents were interviewed and did not express any significant concerns about their health or safety living at the facility. During staff interviews, it was revealed that (R1)had a history of migraines; however, facility staff indicated they had no prior knowledge of (R1) having frequent UTI's and (R1) did not show any signs/symptoms for this prior to being hospitalized. Staff and facility documentation shows that (R1) was independent of services, had meals delivered to their room, and there were no significant changes in (R1's) condition leading up to the fall, including any signs of a UTI. The Health and Wellness Director stated (R1's) only symptom, before being sent to the hospital, was a headache/migraine, which was a chronic issue. *cont on 809C-1... 809C-1.. One staff stated (R1's) fall detect alerted the staff who responded right away and (R1) stated they were "okay" but was in an out of consciousness. One staff recalls (R1) falling a week before and had scratched her head; however, (R1) refused to go to the hospital. EMS was contacted also at that time. Facility charting notes document that (R1) refused to go out for further medical treatment, on 4/23/2025, after falling and when the Emergency Medical Technicians were called. The fax cover page also documents this. (R1's) Physician's Report (dated 4/24/2024) notes resident has a history of migraines, Mild Cognitive Impairment, is independent with all ADL's, and can self administer medications. Charting notes also document that on 5/13/2025 (2:47 pm), (R1) reported not feeling well due to having migraines. (R1's) responsible person was contacted and stated that migraines are normal for (R1), they are on medication and have a follow up appointment at the end of the month. At 9:40 pm, on 5/13/2025, (R1) was checked on again and "no issues were noted- staff to continue to monitor" . There were no additional notes made until resident fell on the morning of 5/17/25. Those notes state that on 5/17/25 (10:04 am) (R1) had an unwitnessed fall in their apartment and was found on the floor. Resident was complaining of pain in both shoulders and their body was shaking while on the floor. Resident appeared confused and stated they lived at a prior care facility. 911 was called for evaluation and resident was taken to Emergency Room. Hospital notes indicate that 911 responders noticed a facial droop and confusion. The Physician's Report (dated 6/18/2024) says (R1) did not require assistance with mobility, transferring, bathing, grooming, dressing and toileting and was independent with medications. (R1's) responsible person was notified and asked that staff ensure medications were available to (R1) as they had an upcoming doctor's appointment. Hospital medical records note a primary cause of death as Urinary Tract Infection (UTI) and a secondary cause as Septic Shock. The county death certificate notes the immediate cause of death to be Septic Shock (onset of hours) and a UTI (onset of days). The administrator discussed and provided documentation showing that migraines and UTI's have many of the same signs/symptoms. Based on information obtained, the Department was not able to substantiate that (R1) passed due to the facility's staff neglect/failure to seek timely medical care. Also, it was clarified during today's inspection that staff (S1), who was interviewed during the investigation, is appropriately cleared/associated to the facility and had a name change. Exit interview. Copy of report provided.