Incident investigation·February 4, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management investigation and was greeted by House Manager/ Administrative Assistant, Charito Santos . Administrator Nicanor Aquino is out of the country and not available. On 2/3/25 CCL received from facility an Incident Report pertaining to resident (R1). On 1/31/25, R1 was taken by ambulance to the hospital after R1 was unable to walk or put pressure on their leg. Facility staff S1 noticed that R1 had a wound on their ankle. R1 was transported from the facility to the hospital by ambulance due to R1 being unable to walk or put pressure on their leg. All required parties notified. On 2/1/25, the facility was notified that R1 had passed away. LPA conducted interviews, reviewed documents, and received copies of documents. LPA's review of R1's most recent Appraisal, Needs, and Services Plan (LIC625) indicates that R1 takes care of their own grooming, showers themselves, but needs reminding to change their incontinence brief. LPA's review of R1's most recent physician's report (LIC602) indicates that R1's capacity for self-care is affirmative with the exception of managing their own cash resources; R1 has the ability to bathe, dress, feed, groom, and care for their own toileting needs. LPA interviewed S1 and asked if they had ever noticed a wound on R1's ankle or if R1 ever had any wounds period. S1 answered that they had never seen any wound on R1 before this morning. S1 explained they saw the wound as they were helping the resident to their feet and with their incontinence brief. S1 explained that R1's medical diagnosis sometimes impairs them and it is during these times that they help R1 with stability. S1 always goes in at the beginning of their shift to change the bed chucks and see if R1 has a soiled brief. R1 does not always soil their briefs, they only wear them in case of accidents. S1 asked R1 to stand and that Continued on 809C.... Continued from 809... is when R1 told S1 that they could not stand without too much pain. S1 noticed the wound on R1's ankle and asked them how the wound got there. R1 answered that they did not know. S1 asked R1 how long has the wound been there because they never saw it before, R1 answered that they did not know. LPA interviewed HM. HM reported to LPA that R1's responsible party (RP) indicated that there was an issue with R1's lungs as they had a long history of smoking and that this was probably the reason for R1's passing but they were not sure. HM reported to LPA that they have asked R1's RP for R1's Death Certificate to provide to CCL once received. No deficiencies cited during this visit.