Incident investigation·April 10, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Kayla Peria, Resident Care Coordinator (RCC). Administrator, Danny Torgersen, arrived at 2:45 pm. LPA stated the reason for the inspection was to follow up on several incident reports submitted to the Department, as follows: Resident (R1) had an unwitnessed fall on 4/1/2026. (R1) denied pain but showed signs of confusion. A non-emergency medical transport company was contacted, arrived to do an assessment and found (R1) to be alert and oriented and refused transport to the Emergency Room. On 4/7/2026 (1:30 pm), (R1) had a witnessed fall while using their walker in the front reception area. (R1) hit their head against the wall and sustained a bruise. (R1) was sent out to the Emergency Room and admitted with a diagnosis of a contained brain bleed. (R1) remained hospitalized and will be returning to the community today, as they are stable. The facility was informed that the medication, Metropolol 25 mg was not administered during part of the hospitalization as it seemed to cause (R1) to be dizzy, perhaps contributing to the falls. The RCC stated that (R1) has used a walker for some time and they believe (R1) is declining overall. The care plan notes (R1) has a history of falls, staff will provide assistance in the case of a fall and there is a fall prevention program in place. Home Health referral is pending for (R1). Resident (R2) had an unwitnessed fall on 4/2/26 (8:35 pm) and sustained some bleeding from their head. (R2) indicated they were trying to get up to get something to drink in their room. (R2) was sent out for further medical assessment and returned the same day with a referral for Home Health and no medication changes. Facility staff have been monitoring (R2) closely, sitting in the nearby hallway and will continue to provide first aid treatment for a small skin tear sustained. *cont on 809C-1.. 809C-1... Resident (R3) and resident (R4) are roommates in Memory Care. On 4/5/2026 (4:10 am), (R4) alleged that (R3) hit (R4) in their head after accusing (R4) of taking their jacket. Staff promptly responded and observed (R4) to be backing out of their room. (R4) was sent out for medical evaluation and returned the same day with a diagnosis of an unknown small bump. The RCC stated labs were done for (R4) and (R4) is back to baseline. The RCC stated staff in Memory Care will conduct "hourly checks" from 7:00 pm- 6:00 am and document on a chart if the resident was awake or sleeping. The RCC confirmed there are (2) caregivers working during the NOC shift as well as (1) Med-Tech. The RCC indicated that (R3) denied hitting (R4), and has had not previously shown aggression towards (R4) or any other resident. The facility timely submitted an incident report and SOC341 for the above incident, as well as incident reports for the other incidents referenced in this report. It appears the facility took appropriate action following each incident in assessing the resident. There are no deficiencies issued in this report. Exit interview. Copy of report provided.