Facility Evaluation Report

On this day, March 19, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on March 2, 2026. LPA met with Geraldine Tayo, interim administrator (IADM), and informed the reason for visit.

UIR indicated that on February 28, 2026, at around 2:35 pm, resident (R1) was found on the floor in his living room by care staff during safety check. R1 presented with confusion and bruises on the back and face. R1 was sent out and came back the same day. R1 was diagnosed with a transverse process fracture on lower back which will heal on his own time.

LPA reviewed R1's file and obtained copies of including but not limited to LIC602A Physician's Reports before and after fall incident; Notification of Hospice Initiation; Death Report; Appraisal; LIC625 Appraisal/Needs and Services Plan; hospital After Visit Summary

LPA conducted interview. IADM stated R1 was placed on hospice care on March 4, 2026 and passed away after few days. Death Report showed R1 passed away on March 7, 2026.

Exit interview conducted and copy of this report provided.