Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to several incident reports received in the last few weeks. LPA met with Margarita Guerrero, Business Office Director, initially, and then Mike Talani, Administrator, Lance Ramos, Memory Care Director (MCD), and Nekia Xavier, LVN Health and Wellness Director (HWD). LPA stated the reason for the inspection. The following residents and incident reports were discussed, as follows:

On 5/1/24, resident (R1) was found after an unwitnessed fall in her room on 4/23/24. Resident was sent to the emergency room (ER) due to observing a cut on her forehead. Resident was admitted to the hospital and received surgery for a left hip fracture. Resident was also diagnosed with a small brain bleed. Resident was independent in her care needs prior to this fall. HWD confirmed resident recently returned and is doing well.

On 4/8/24, resident (R2) fell and sustained a scalp injury. Resident was sent out to the ER immediately and received two staples to her scalp, returning the same day. MCD stated resident is doing well and had the staples removed (10) days later. Resident has a pending order for physical therapy.

On 4/14/24, resident (R3) had an unwitnessed fall in his room at 12:40 am, when trying to ambulate to the restroom. Resident would regularly refuse to use his walker, despite many staff, including the in-house physical therapist, encouraging the use of a walker. Prior to this fall, resident had completed a screening with the in-house Physical Therapist and was using the walker more often but was still seen to be ambulating without using one. Resident remains in skilled nursing and is participating in physical therapy until he is stronger to return to the community.

On 4/16/24, resident (R4) was found on the floor in her room at 3:30 am and was transported to the ER for further medical evaluation. Resident returned on 4/18/24 with orders for PT, OT, Home Health and antibiotics. Resident will be evaluated if hospice care is appropriate. Resident has swelling in her legs and sometimes tries to get up her own without assistance from staff of a device. Resident's care plan updated.