Incident investigation·April 2, 2025

On April 02, 2025, at 10:30 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding a death report for Resident (R1) that was received by the department on March 25, 2025. Upon arrival, the LPA was greeted by the Executive Director (ED), Flavio Silva. The LPA disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 88. According to R1’s Death Report, R1 had a fall at the facility on 03-18-2025 and was transported to the hospital, but the Licensing department had not received an Unusual Incident Report for R1’s fall and subsequent admission to the hospital. ED provided a copy of the Unusual Incident Report to the LPA for R1’s fall on 03-18-2025 and a copy of the fax transmittal page that showed the Unusual Incident Report was successfully faxed to the Licensing department on 03-18-2025 at 4:01 PM. ED stated that R1 had a fall on 03-18-2025 and a caregiver found R1 on the floor inside R1’s room in front of a chair. Care staff asked R1 if they could get up. R1 stated that they could not get up and said they were in pain. 911 was called and R1 was transported to the hospital. R1’s family and primary care physician (PCP) were notified. ED further stated that R1 was not necessarily a fall risk, and prior to the fall on 03-18-2025, R1 had been falling on and off. However, there was never a need to call 911 since R1 had been able to get up and had not reported any pain. Continued on LIC809-C ED stated that they spoke with R1’s family around 03-21-2025 or 03-22-2025. R1’s family told the ED that R1 was agitated in the hospital, screaming in pain, and the family was planning to place R1 on hospice. R1’s family called the ED on 03-24-2025 to share the news of R1’s passing and asked when they could empty R1’s room. There was no complaint from R1’s family about anything. The ED further stated that they did not have R1’s hospital discharge notes, as R1 did not return to the facility after being discharged from the hospital. LPA reviewed R’s charting notes. On 01-24-2025 R1 had a fall in the hallway. R1 stated that they missed a step and fell down. R1 stated they didn’t hit their head nor were in pain. Care staff assisted R1 to stand up. On 03-11-2025, R1 fell from sitting on their walker while having lunch in the dining room. R1 stated they were ok, landed on their bottom, and didn’t hit their head. Care staff assisted R1 to sit back on the chair. R1’s family and PCP were notified. LPA reviewed R1’s LIC602 Physician’s Assessment Report, dated 10/19/2022, which stated that R1 was non-ambulatory and was able to independently transfer to and from the bed. LPA reviewed R1’s Functional Capabilities document, dated 02-22-2025, which stated that R1 used a walker and/or wheelchair. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Flavio Silva, whose signature on this form confirms receipt of the report.