Incident investigation·May 14, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Magda Luis, Interim Administrator. LPA stated the reason for the inspection was to follow up on (2) incident reports recently submitted to the Department. LPA discussed the incident reports in the Administrator's new office space that was in the process of being converted from the salon. Resident (R1) fell in the lobby area on May 8, 2026 (2:50 pm). The receptionist observed (R1) to be lying on the floor with their elbow and upper right arm bleeding due to sustaining a skin tear after the fall. Emergency medical services were contacted, arrived at 3:10 pm, and assessed (R1), who was sent out for further medical evaluation due to a possible head injury. Hospital discharge paperwork notes that (R1) returned to the facility the same day with a discharge diagnosis of Closed Head Injury and Skin Tear of upper extremity. The administrator stated (R1) tends to ambulate too quickly with their wheelchair, and staff needs to continue providing reminders to walk slower. LPA and the administrator observed (R1) to be ambulating with their wheelchair throughout the corridors during today's inspection. Resident (R2) complained of chest pain and dizziness on May 9 ,2026 (2:00 pm). A Med-Tech staff attempted to contacted Home Health at 2:00 pm and then called emergency medical services who arrived at 3:05 pm. The Administrator, primary care physician and responsible person were also notified. (R2) returned the same day with no changes and will follow up with their primary care physician. The facility placed (R2) on (4) status checks each shift and will contact the primary care physician with any changes in condition. LPA and the Administrator observed (R2) resting comfortably in their room during the inspection. The administrator stated (R2's) symptoms were attributable to a secondary diagnosis of anxiety. It appears the facility took timely action in seeking medical attention for each resident. There are no deficiencies issued in this report. Exit interview. Report provided.