Incident investigation·March 25, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and discussed with Kim Rosa, House Manager. A required annual inspection was also conducted today. During this inspection, LPA and House Manger discussed the following (3) incident reports, as follows: Resident (R1) was found on the floor in their room on the morning of January 15, 2025. Staff contacted hospice personnel who arrived to check resident's vitals. 9-1-1 was also contacted and determined resident's vitals to be stable. Resident remained at the community and passed at 11:00 pm that day. Resident moved in in December 2024 and had been on hospice for many months prior to that. A Death report was submitted to the Department on January 22, 2025, by regular USPS mail. Resident (R2) was observed to be not breathing properly while eating dinner on February 6, 2025. Resident was sent to the emergency room and returned to the facility on the morning of February 15, 2025, under hospice care. Resident has been doing well and has not needed any oxygen since being placed on hospice. Resident (R3) moved to the facility on February 3, 2025, after sustaining one or more falls at home. On February 26, 2025, resident was found on the bathroom floor during staff shift change. Staff stated resident didn't request help and got up on their own. Staff called emergency services who assessed them and sent them to the hospital for further evaluation. Resident sustained a fractured pelvic, has been in rehabilitation and will be returning in a couple of weeks. LPA discussed with the House Manager how incident reports should be as complete as possible, including follow up information from the hospital. Staff training will be conducted- Also discussed how reports can be faxed in more quickly. There are no deficiencies issued in this report. Exit interview. Report provided.