Incident investigation·June 6, 2023

Licensing Program Analyst (LPA) Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Brandee Rodriguez. Facility submitted reports regarding resident, R1 who was recently discharged from hospice services. Per reports resident was found on the floor by staff. Resident denied pain and/or hitting their head. Later, when resident started complaining of pain, they were transported to the hospital. Resident passed away at the hospital three days later. Per file review, resident did not require 1:1 supervision. Facility has requested the Death Certificate. Once received, facility will send a copy to the Department. No deficiencies cited during this inspection.