Incident investigation·August 29, 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 residents/reports submitted to the Department: On 8/26/25, resident (R2) was found holding resident (R1) by the top of their shirt and yelling that (R1) had entered their room and taken a personal item. The Administrator stated (R1/R2) used to be roommates and (R1) was confused and went in the room and took a sweater. Staff immediately intervened and neither resident was observed to have any injuries. (R1) recalled the incident and stated this was the only incident with (R2) and staff assisted promptly. (R2) was not able to recall any part of the incident. LPA observed (R2) to be sitting with a 1:1 care staff, who confirmed she has been providing 1:1 supervision to (R2) who has shown no aggression since this first incident. The Administrator confirmed (R2) started taking newly prescribed medications following the incident and the 1:1 will continue for two weeks approximately. LPA and Administrator discussed resident (R3) who was evaluated for a leg wound and rash on 8/26/25 while attending a day program. (R3) was prescribed a creme to treat scabies and received the first treatment on 8/26/25 and will receive the second treatment on 9/2/25. LPA observed a stocked PPE cart outside (R3's) room during today's inspection and also a staff who was cleaning in the room to be wearing PPE (N95 mask, gloves and shoe coverings). The Administrator stated no other residents or staff currently have signs of a rash, and (R3) is being quarantined in their room. LPA and the Administrator discussed resident (R4) who had (2) falls at the facility, on 7/27/25 and on 8/1/25. (R4's) family and hospice refused to send (R4) to the emergency room except for on 8/13/25, when (R4) was complaining of abdominal pain. *cont on 809C-1.. 809C-1.... The Administrator stated (R4) would always yell/scream for assistance and would sleep a lot also. The Administrator stated (R4) would not have been able to snap/unsnap a belt to keep them upright in the wheelchair. After the fall on 8/1/25 (1:00 pm), hospice staff recommended that (R4) be up in their wheelchair for an hour after meals to assist with digestion. Additionally, hospice nurses would visit 2 times weekly and (R4) would receive bed baths twice weekly also from an assistant. The Administrator stated that hospice never indicated that (R4) had sustained any rib fractures. It appears the facility took appropriate actions following each incident in seeking medical care and reporting to the department. There are no citations issued in this report. Exit interview. Copy of report provided.