Follow-up·September 9, 2025

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on five self-incident report and one death report dated between 8/25/25 & 9/5/25 received by the department regarding falls in assisted living unit and met with Patricia Gustin, Administrator. Death report received on 8/27/25 indicates that on 8/25/25 the facility was notified by an outside party that resident (R1) passed away on 8/25/25 while in the hospital. Previously, on 8/12/25 the department received a self-incident report notifying CCL about R1's hospitalization on 8/7/25 due to altered mental status and weakness. During today's visit, LPA requested death certificate because R1 was not receiving hospice services at the time of their passing. According to death report, R1 had a diagnosis of cirrhosis of the liver, kidney failure and hypertensive heart disease. -On 8/29/25, incident received dated 8/20/25 resident (R2) called for assistance due to a fall after returning from the hospital, staff called 911 to transport R2 back to the hospital for increased falls and change of condition, responsible parties were notified. Today, LPA learned that R2 was transferred to a rehabilitation facility for treatment and there is no date for them to return to the facility. -On 8/29/25, incident dated 8/27/25 reported that resident (R3) was observed by med-technician while passing their medications that R3 was lying on the floor in a prone position with their walker positioned on their back. Continues on LIC809C... Continued from LIC809... R3 could not tell staff how the incident occurred, no injuries were noted, but staff determined to call 911 to transport R3 for further evaluation, responsible parties were notified. During today's visit, LPA reviewed R3's records including care plan updated on 8/30/25 that reflects the change of condition alerting staff of heightened risk for falling. -On 8/29/25, third incident report dated 8/27/25 indicates that resident (R4) pressed their call alert pendant at about 1:15pm, upon staff arrival, family member was present in their room and told staff that R4 had fallen while arising from off the toilet and reported that R4 struck their head, staff assessed R4, but there were no visible injuries noted and R4 denied any acute pain nor discomfort, and staff followed the facility protocol to call 911 to transport R4 to the hospital for further evaluation. R4 was diagnosed with a closed heads injury and no new orders were issued. R4 was placed on increased round checks to be monitored for any further effects from the fall. On 9/5/25 another incident report was submitted to CCL notifying that on 9/1/25 at approximate 3pm, staff entered R4's apartment and noticed that R4's recliner had tipped over, R4 was seated on the floor next to the chair, and they were unable to recall what happened, R4 appeared confused, staff assessed them and called 911. Emergency team determined that R4 had a very slow and irregular heartbeat and they transport them to the emergency room for further assessment. Responsible parties were notified. R4 returned to the community same day and have been placed on alerting chart. Today, LPA was provided with updated care plan dated 8/27/25 including increased assistance needed in the bathroom to reduce fall risk considering a review of current medications with their physician to reduce the possibility of side effects. The last incident report received on 9/2/25 it was dated 8/30/25 indicating that resident (R5) was noticed by staff wandering in the hallways which was unusual for the resident. R5 could not remember when was the last time that they ate nor even if they had a recent bowel movement. Staff assessed the resident and did not observe any signs of injury, but they called 911 and resident was taken to the emergency room for further evaluation. Responsible parties were notified. LPA was informed that the facility is currently in the process of obtaining updated physician to update their care plan. No citations were issued during today's visit. Exit interview conducted with Administrator and copy of this report was given.