Incident investigation·March 25, 2025

Licensing Program Analyst (LPA) Sabrina Calzada and Ombudsman arrived unannounced to conduct a case management inspection. LPA met with Director of Nursing, Karen Padilla and Administrator, Danny Torgersen, and stated the reason for the inspection.LPA, Ombudsman and both facility managers discussed the following incidents recently reported to the Department, as follows: Resident (R1) had an altercation with resident (R2) who entered their room on March 23, 2025 (7:00 pm). Staff stated (R2) may have wandered in (R1's) room, mistakenly, and (R1) may have tried to be aggressive with (R2) and then (R2) may have hit (R1) on the lip. Both residents were sent to the ER. (R1) returned with sutures to their upper left lip and (R2) remains in the hospital as they have shown behaviors there. Resident (R3) was observed to be on the floor with their left eye cheek swollen on March 22, 2025. Staff stated resident fell going to the bathroom. Resident was sent out for emergency treatment and returned the same day. Resident (R4) was found on the floor in the bathroom on March 22, 2025. Resident was observed with a skin tear on their left forearm and a fracture of their right hip. DON stated the hospital will keep resident for 3-4 additional days before sending them to a skilled nursing. Resident was receiving physical/occupational therapy before the fall and moved in from a skilled nursing facility. Resident (R5) was observed to be in (R1's) room on March 18, 2025, (6:00 pm) by staff after hearing (R1) screaming. Staff was able to redirect (R5) from (R1's) room and there were no injuries observed. Both residents are being monitored for behaviors. (R1) didn't remember the incident and (R5) is currently non-verbal and taking antibiotics for a Urinary Tract Infection, which could have caused the confusion. 809C-1.. Resident (R6) was interviewed by LPA and the Ombudsman. Resident was observed to be resting in their room at the time of the discussion. Resident expressed concern about their medical group not addressing the reason for the recent trip to the emergency room on March 24, 2025. Resident confirmed she is receiving showers at least twice weekly, and staff is assisting with applying lotion for their skin condition. The DON confirmed that (R6) was prescribed a 10-day oral antibiotic and a topical creme following yesterday's visit to the emergency room. It appears the facility followed its protocols in sending all residents out for further medical evaluations. LPA requested updated care plans for residents (R2) and (R5) and hospital discharge paperwork for the last several hospital visits for (R6). There are no citations issued in this report. Exit interview. Copy of report to be emailed following today's inspection.