Incident investigation·October 10, 2025

LPA Johnson arrived to the facility unannounced to conduct a case management visit based on an incident reports submitted to the department on 10/5/2025. It was reported to the department that at approximately 3:30pm on 10/3/2025, R1 reported pain on the left side. R1 had an unwitnessed fall on 9/30/2025 and refused treatment by the emergency medical service on that day. R1 continued to be uncomfortable for three days until he requested to go to the ER to be evaluated on the afternoon of 10/3/2025. R1 was sent out and diagnosed with an UTI and multiple fractures of the ribs on the left side. Medications were ordered and follow-up with primary care physician (PCP) ordered by 10/6/2025 which is 3 days after the incidents or ER discharge. During the inspection LPA toured the facility and discovered multiple issues in the kitchen including, broken thermostat, equipment not operational, drainage issues resulting in puddling on the floor in front of the main oven, mirror not secured on the fireplace mantel and black smoke stains on the walls in the dining area. Deficiencies cited on the attached 809D page. Exit interview conducted and appeal rights given.