Incident investigation·December 4, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for today's inspection was to discuss (2) incident reports recently submitted to the Department. LPA met with Interim Administrator, Magda Luis, at 11:35 am. LPA and RCC discussed resident (R1) who fell in their room on November 21, 2025 (8:35 am). Staff found (R1) sitting on their bed and bleeding from a wound on the upper right side of their forehead that was sustained from a previous fall on October 29, 2025. A Med-Tech contacted (R1's) health care provider around 9:00 am to inform of the bleeding and was advised to apply pressure to control the bleeding. At 9:33 am, the Med-Tech called the health care provider back to advise that the bleeding from the wound was not able to be controlled, and (R1) stated they were feeling light-headed. The facility was advised to send (R1) to the Emergency Room and a medical transport arrived at 10:05 am. (R1) returned to the community later the same day and with no new orders. The RCC stated (R1) has the habit of picking their wound and since this incident, staff have placed a wrap around (R1's) head to deter resident from picking the wound. Staff will also try and redirect (R1) if they are observed to be picking at the wound and they will continue to provide first aid care. The administrator stated (R1's) wound is healing well. LPA and RCC discussed a recent fall for resident (R2) with the hospice nurse who was present. (R2) fell on November 22, 2025 (12:50 pm) out of bed onto the floor and was bleeding from their nose and mouth. Staff immediately contacted the hospice company and was not able to speak to a nurse until 1:30 pm, at which time hospice staff advised that (R2) be sent to the emergency room. Discharge papers show (R2) was treated for a fall and a "comminuted fracture of nasal bone". cont on 809C-1.. 809C-1.. The RCC stated that (R2) has been very active lately and staff are monitoring them more. RCC added that (R2) has not been eating lately and hospice is making daily visits. The hospice nurse joined the conversation and confirmed (R2) began receiving hospice services on November 19, 2025 and last ate solids on November 23, 2025, following their last fall. The nurse explained that (R2) is not able to swallow at this time and their medications, Lorazepam and blood pressure have been stopped since they may have been contributing to the falls. The nurse explained that medications for pain have increased and the medication changes seem to be effective as (R2) has not fallen since, and (R2's) vitals remain good. The nurse and RCC confirmed that (R2) is taking sips of liquid only at this time, and is sometimes is able to take them with a straw. The nurse added that the facility care givers have been providing extra care and more frequent checks to (R2) and staff has also been continually contacting hospice with any questions. The nurse stated that a nurse has visited daily to ensure all medication orders/changes were made effectively. LPA reminded the RCC and Interim Adminisrator to be sure to submit all incident reports to the department within (7) calendar days of the incident occurring. It appears the facility took appropriate and timely action in sending each resident out for further medical evaluation. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the facility.