Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC) and Administrator Designee. LPA stated the reason for the inspection was to follow up on several incident reports (LIC624) submitted to the Department in June, 2026. There are currently (4) residents under hospice care. LPA and the RCC discussed the following:

Resident (R1) had an unwitnessed fall on 6/26/2026 ( 5:00 pm), was evaluated by emergency personnel and sent out for further medical attention. (R1) indicated to care staff that they hit their head but did not complain of pain. (R1) returned the same day with no injuries and with new orders to use a walker and start Home Health (Physical Therapy). (R1's) care plan was updated to note the use of a walker. (R1) is making progress with using their walker and PT visits 2x/week.

Resident (R2) complained of chest pain on 5/30/26 (11:50 am) and on 6/10/26 (5:20 pm). R2 was evaluated by emergency personnel and sent out for further medical attention. (R2) returned to the community following each hospital visit and test results noted there were no signs of a heart attack, blood clot or pneumonia. (R2) was advised to follow up with their primary care physician. Staff has continued to monitor (R2) for any changes in condition. No changes were made to resident's medications after each visit.

Resident (R3) had an unwitnesed fall on 6/8/26 (5:20 pm), after becoming dizzy following dinner. (R3) fell on their left side, and reported pain on their left wrist, left hip and stated they hit their head. (R3) returned to the community on 6/9/26 (12:45 am) and is using a wheelchair currently due to their hip fracture. Home Health (Physical therapy) was started two weeks ago and resident is doing better. (R3's) care plan was updated to reflect resident needing stand-by assists with ADL's and transfers and increased safety checks.