Follow-up·December 15, 2025

On 12/15/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator . 12/9/25, the department received a death report of R1's passing on 12/8/25 while in caret. Records review found R1 was diagnosed with hypertension and congestive heart failure. On 10/12/25, R1 experienced a fall and was seen at the hospital. Since that time, it was reported that R1 experienced decline in alertness and nutrition. While R1 had frequent family involvement, Administrator reported observed decline to family of R1 but not to R1's primary physician . Therefore, licensee did not ensure that such changes are documented and brought to the attention of the resident's physician in a timely manner. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided