Incident investigation·May 14, 2025

On May 14, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 5/1/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit. The Licensee reported, on 5/1/25, Staff 1 (S1) reported to the Administrator that Staff 2 (S2) was given cash by Resident 1 (R1) to fix R1's bed. S2 was immediately put on suspension pending facility's investigation. During the visit, LPA interviewed staff, reviewed R1's file, attempted to interview R1 and S2, and observed R1's bed. LPA was unable to interview R1 and S2 as they were not at the facility during the visit. According to R1's physician's report, R1 does not have any confused/disoriented behavior and is able to communicate needs, in addition to manage his/her own cash. According to staff interviewed, R1 reported to the staff that his/her bed was broken and staff immediately addressed it with the Assistant administrator and the administrator. According to the Assistant administrator and staff interviewed, it took 3 days for a third party vendor to fix R1's bed because R1 has a special geriatric bed and the facility needed to call a third party vendor to come fix it, however during those 3 days, R1 insisted to pay S2 to fix his/her bed. Because S2 couldn't fix the bed, S2 returned the money to R1. During the visit, LPA observed R1's bed fixed and in good working condition. An in-service training was immediately conducted the same day and another in-service training will be conducted on 5/16/25. No citations are issued during the visit. Report is reviewed with the Assistant administrator and a copy is provided.