Incident investigation·July 31, 2025

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced case management visit on this date. LPA met with Staff and explained the purpose of the visit. The department received an incident report that during Physical Therapy session R1 all of a sudden vomitted black emesis. Staff rushed to patients side and assessed condition and immediately called 911 for medical assistance. Family notified right after report was made. The facility did not send a follow-up report and this is the reason for the visit today from the department today. During the visit today the department learned that R1 will not be returning to the facility, R1 will be released to another facility that will provide R1 with a higher level of care. The facility was given an advisory regarding updating and/or completing the LIC 624 incident report form with complete or additional information when that information is made available to the facility.