Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, and Ashley Stahl, Resident Care Coordinator. LPA stated the reason for the inspection was to follow up on several incident reports and death reports. The following was discussed:

Resident (R1) was verbally aggressive on 5/13/25 to staff, refusing ADL's, and provoking other residents. Resident was sent out and returned the same day with a diagnosis of UTI and antibiotics. Resident is doing better a week later. Resident (R2) had an incident involving feces on 4/23/25 and was sent out that day. Resident's labs returned normal. This was a first incident of this kind for this resident.. Resident's care plan was updated to reflect this behavior. Recently, the Administrator recommended placing resident under hospice care to family due to a noticeable decline. . Additional monitoring with more frequent checks has been implemented and specific undergarment/clothing zip ups have also been suggested.

Resident (R3) moved out of the facility recently, on 5/7/25, due to past aggressive behaviors.

Resident (R4) was sent to the emergency room on 12/28/24, for an altered level of consciousness. Resident passed on 12/29/24 at the hospital. LPA obtained documentation previously by email but did not conduct a case management inspection.

Resident (R5) fell on 1/22/25, was sent to the hospital and diagnosed with a fractured hip. Resident returned the next day with a referral for hospice. Resident passed on 2/6/25. LPA re- requested care plan in effect prior to the fall - due by 5/22/25. LPA had previously received a copy of the updated care plan following the fall.

There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.