Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted a Case Management–Incident visit at the above facility. Upon arrival, LPA met with facility staff and explained the purpose of the visit.On May 22, 2026, Community Care Licensing (CCL) received a Death Report regarding Resident #1 (R1). According to the report, on May 8, 2026, at approximately 4:00 PM, R1 was sitting in the living room watching television. R1 then stood up and began walking toward the front door. While approaching the front entrance, which contains a low ramp, R1 reportedly slipped, fell backward, and struck their head. The Death Report indicated that Staff #1 (S1) immediately responded and assessed R1. S1 observed a small bump on R1’s head, along with a minor laceration and scant bleeding. S1 contacted R1’s wife and informed her of the incident. According to the report, R1’s wife instructed staff not to call emergency medical services immediately and advised that she would be arriving at the facility shortly. Approximately 20 minutes later, R1’s wife arrived at the facility and decided to contact emergency medical services. R1 was subsequently transported to Holy Cross Medical Center for evaluation and treatment. The Death Report further indicated that R1 was later diagnosed with a skull fracture and moderate intracranial bleeding.During today’s visit, LPA interviewed two staff members and obtained copies of R1’s records for review. At this time, LPA is unable to close out the investigation. Additional information needed prior to concluding investigation. Facility representative was advised and a copy of this report given.