Incident investigation·May 7, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Magda Luis, Interim Administrator and Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for the inspection. LPA, the Administrator and the RCC discussed the following (2) recent incident reports recently submitted to the Department. Resident (R1) had an unwitnessed fall in their room on 5/1/26 (4:00 pm) and fell face down on their face. Emergency Services were called due to the observed injury and (R1) was admitted to the hospital with a diagnosis of a nasal fracture. (R1) returned to the community on 5/4/2026 and went to a follow up medical appointment where there were some medication changes, including for pain medication. LPA observed (R1) resting in their bed at the start of today's inspection. LPA observed bruising on (R1's) nose and mouth/chin area. (R1's) family member arrived to take resident to a scheduled medical appointment. LPA reminded (R1) to ask for assistance when trying to get up and ambulate and to use their walker, which was in the room. The Interim Administrator stated (R1) probably fell when trying to get up from bed quickly, confirming (R1) is eating well and will let staff know if they are experiencing pain. The RCC stated a bed alarm has been placed near (R1's) bed and (R1) is also using a walker more. The Administrator confirmed this is the first fall for (R1) since moving to the community in January 2026. LPA discussed the recent hospice death of resident (R2) on 5/2/2026. The Administrator stated (R2) passed peacefully and had not exhibited any behaviors recently since being admitted to hospice in August 2025. The facility took appropriate and timely action in seeking medical care for (R1) after their fall. There are no citations issued in this report . Exit interview. Copy of report provided.