Incident investigation·December 19, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to follow up on several incident reports submitted to the Department. LPA met with Karen Padilla, Director of Nursing, and stated the reason for the inspection. The following incident reports (LIC624) were discussed: Resident (R1) fell out of their bed on 12/16/25 (3:20 am) and a Med-Tech was notified by resident's roommate. (R1) was found lying on the floor in a side-lying position and stated they fell asleep at the edge of the bed and fell. No bruises or injuries were noted when resident was assessed. The DON stated on 12/19/25 that the facility is discussing getting a recliner chair for (R1) to sleep in and will contact the physician for approval. Currently (R1) is hospitalized for a diagnosis that affects how the resident sleeps. Resident (R2) was offered a prohibited substance on 12/9/25 (6:30 pm) from (R3) who received it from resident (R4). (R2) was sent out for further medical care and evaluation after showing signs of distress. (R2) returned from the hospital on 12/10/25 (1:40 am) after labs were cleared. No new orders were given. (R4) is independent and able to leave the facility unassisted and returned with the prohibited substance. The DON stated local Sheriff came out and spoke to residents (R2 and R4) who were reminded of the facility's policies and understand they can be issued a (30)-day eviction notice if the policies are not followed. Resident (R5) became aggressive towards staff and residents on 11/15/25 (4:00 pm) and began picking up chairs and attempting to strike. Care staff promptly intervened and (R5) was redirected back to their room prior to be sent out for further medical evaluation. (R5) returned the same day with a diagnosis of a Urinary Tract Infection and began a 7-day antibiotic. The DON stated (R5) frequently has behavior and the family also agrees to send resident out for further medical evaluation. During the day (R5) has less behaviors and the current care plan addresses these sundowning behaviors. *cont on 809C-1.. 809C-1 Resident (R6) had an unwitnessed fall on 12/17/25 (6:35 pm) and found on the floor in the activity room. (R6) was immediately assessed by a Med-Tech and no injuries/bruising were noted, nor any complaints of pain/discomfort. (R6's) responsible person was notified and staff continued to monitor resident. The DON stated today she is a moderate fall risk and doesn't have peripheral vision on both sides, so increases the risk of falling. (R6) is a wanderer throughout the hallways in Memory Care. It appears the facility took appropriate action in each of the above incidents noted. There are no deficiencies issued in this report. Exit interview. Copy of report provided.