Incident investigation·July 14, 2025

"LPA Johnson arrived to the facility unannounced to conduct a case management visit based on two incident reports submitted to the department on 7/08/2025. It was reported to the department that at approximately 10:00 AM, R1 reported that after breakfast she felt fatigue. RCD checked blood pressure and was reading at 70/45. R1 reported no dizziness, no blurred vision, no confusion noted and did not want to seek further medical attention. RCD encouraged R1, but R1 refused. RCD encouraged R1 to eat salty snacks/food and will come back to check resident alter 30 minutes. RCD checked R1's blood pressure after 30 minutes with no change. R1 was encouraged again to go to the R1 agreed. 911 was called and R1 was transported to SJMC. Shanel Thitphaneth, LVN/RCD witnessed the event as reported. R1 was admitted to the hospital for observation. LPA reviewed resident's files and reviewed pertinent documentation related to this facility. As a result of this incident the resident was sent out on 7/08/2025 and has not returned. The facility will reassess R1 before she returns. Continued 911 was immediately called due to MT noting R2 with labored breathing and lips turning purple with oxygen on. RP was called and R2 was taken to St. Joseph's Medical Center for further treatment. R2 on 07/08/2025 at around 11:00 AM with admitting diagnosis of pneumothorax. RP is aware and is currently with R2 at the hospital. The facility will continue to follow-up on resident's status until her return from the hospital. No deficiencies were cited on today's visit Exit interview conducted.