Follow-up·September 18, 2025

Licensing Program Analyst (LPA) Sabrina Calzada and Licensing Program Manager (LPM) Maribeth Senty arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, stating the reason for today's inspection. LPA, LPM and the Administrator discussed the following residents/reports submitted to the Department: Resident (R1's) change in condition that occurred on/around 7/25/25 was discussed. Resident's care plan was updated then to reflect (R1's) refusal of care. During today's inspection, (R1's) medical professional was contacted by phone and explained recent steps taken due to (R1) starting with them, including medication management and changes. It was agreed that the facility will issue a 30-day notice to (R1) and responsible person/s since (R1) continues to refuse essential care. The Administrator agreed to provide a copy of the 30-day notice to the Department for review within (5) days of its issuance. Resident (R2) passed on September 9, 2025 at the facility and was under Palliative/end of life care. (R2) had several falls starting in August 2025 and was sent to the hospital on 8/13/2025 after suffering a stroke while attending their health care center. (R2) returned on August 14,2025 and palliative care was started. The Administrator contacted the Med-Tech staff who observed (R2) who had fallen out of bed on 9/9/25. This staff explained what position (R2) was found in and provided a photograph during the discussion. (R2's) head was between a pillow and the mattress and was not stuck in the bed rails as the facility earlier reported. The facility will submit an incident report for the incident on 9/8/25 since non-emergency medical technicians responded after the fall and assisted (R2) back into bed. *cont 809C-1.. 809C-1.. Resident (R3) was allegedly hit by staff (S1) on 9/6/25 (5:00 pm) when in the dining room. This event was reported to the Administrator by a non-staff person who described (R3) as having an aggressive behavior prior to (S1) hitting (R2) back on the left shoulder. An internal investigation was conducted and it was determined that (S1) was not observed by other staff to strike (R3). Additionally, the Ombudsman investigated the alleged abuse and spoke with (R3) who stated they were not struck, which was consistent with what the facility determined. LPA was provided with a copy of the SOC341 during today's inspection that showed the report was faxed successfully on 9/15/25 (11:32 am). LPA reminded the Administrator that incident reports are due within (7) days of the incident to the Department. It was agreed that due to not having sufficient evidence, (S1) would be able to return to work. Additionally, (S1) has worked at the community for a couple of years and there have been no prior concerns/complaints. (S1) will be assigned to another side of the building upon return. Additionally, cameras may be placed in the dining rooms. The facility appears to have followed facility protocols for working with the resident in trying to provide care, seeking timely medical assistance and placing a staff on administrative leave when an internal investigation is warranted. A tour was also conducted of the interior. There are no deficiencies issued in this report. Exit interview. Copy of report provided.