Incident investigation·May 9, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management investigation. LPA met with Director of Nursing (DON), Karen Padilla, and stated the reason for the inspection. LPA discussed recent incidents reported to the department and obtained individual Pre-Assessments and Care Plans for the following residents: Resident (R1) recently obtained an updated Physician's Report (LIC602) and faxed a copy to the department reflecting an updated change. The DON stated one of the pages appears to have been completed by a different person than the person who completed the other pages, and the faxed dates do not match either. The DON stated she is waiting for a return call from the doctor to discuss further. On April 19, 2025 (6:50 pm), Resident (R2) pushed resident (R3). (R3) retaliated by pushing (R2) back against the wall. (R2) was taken to their room, assessed and observed to have a skin tear on the left arm and a possible hip fracture. (R3) was redirected back to their room. Hospice staff was contacted and advised (R2) have an x-ray taken, so (R2) was sent out. (R2) was diagnosed with a hip fracture, had surgery on 4/20/25 and returned to the community and later passed on May 2, 2025, while under hospice care. On April 20,2025, resident (R4) was observed by a Med-Tech staff to be physically and verbally aggressive with another staff and was sent out for further medical evaluation. (R4) returned with a change in medication -Seroquel was increased to 50mg at bedtime for agitation, and a PRN order was also added - 100 mg to be added three times per day, as needed, for agitation. The DON stated resident is showing less aggression. It appears the facility acted timely in seeking outside medical help. There are no deficiencies being issued. Exit interview. Copy of report provided.