Incident investigation·April 3, 2025

On 04/03/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a Case Management regarding an Unusual Incident Report (UIR) for a 03/21/25 incident. LPA Campbell met with Administration John Villareal and explained the purpose of the visit. The resident had gone to the hospital on 03/18/2025 due to low blood pressure and an inability to stand. After the resident was discharged from the hospital on 03/20/25, he was no longer able to stand on his own and continuously fell from his bed and lost control of his bodily functions. Per the administrator, the facility could not meet his needs. The administrator contacted R1's Case Worker, Sonia Martin from Turning Point. The Case Worker called 911 and asked A to retrieve R1 from the facility and return them to the hospital because R1 was extremely weak and could not stand. The case worker was contacted by LPA Campbell but could not speak without an ROI. Once received, there could be further discussion At this time, no deficiency is being cited. This incident is currently under review and a future citations or penalties may apply. Exit interview conducted and appeal rights provided.