Incident investigation·July 10, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, stating the reason for today's inspection. LPA and Administrator discussed the following incident reports submitted to the Department, from June 20, 2025 to July 1, 2025. Resident (R1) was observed to have a rash on their back during ADL's on June 24, 2025 (2:00 pm). Resident was sent to the Emergency Room and returned the same day with a prescription for Triamcinolone 0.1% cream. Resident was placed on alert charting to include checks (4) times daily. Two treatments were administered. Resident is currently doing fine, and the rash has disappeared. This is the only case of suspected scabies in the building, and (R1) did not have a roommate. On June 24, 2025 (6:45 pm) resident (R2) was observed to be very agitated and physical with (2) staff, barricading them in their room and not allowing the Med-Tech to administer medication. Resident was sent to the hospital for further evaluation and returned in June 26, 2025 with a new medication, Risperidone 5 mg. LPA received a copy of the completed Behavioral Expression Assessment and updated resident's care plan upon their return. Resident went back on hospice following their return. On June 25, 2025 (12:00 pm), resident (R3) hit resident (R4) with a fork. Neither resident was injured and the residents were immediately separated. The facility completed a SOC341 following the incident and the Ombudsman also investigated. (R3'x) Seroquel dosage was increased and a 1:1 care staff was implemented immediately following the incident. *cont on 809-C.1 809C-1.. Resident (R5), who is a known fall risk, was observed to be walking out of their room without a walker or wheelchair, on June 27, 2025 (8:15 am). While staff was redirecting resident back to their bed or chair, (R5) pulled away and fell on the floor, hitting their side of their body. Resident was sent to the emergency room, and diagnosed with a broken rib. Resident was prescribed pain medications and placed on more frequent checks (4x/day). Resident's family member visits regularly. Resident is recovering well with minimal pain medications and is cooperating with using the wheelchair now. A fall mat has been requested and resident's bed has been lowered. It appears the facility promptly sent residents out for further medical attention in each of the (4) above incidents. There are no deficiencies issued in this report. Exit interview. Copy of report provided.