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). LPA stated the reason for today's inspection was to discuss (2) incident reports recently submitted to the Department. LPA met with Interim Administrator, Magda Luis, at 11:35 am.

LPA and RCC discussed resident (R1) who fell in their room on November 21, 2025 (8:35 am). Staff found (R1) sitting on their bed and bleeding from a wound on the upper right side of their forehead that was sustained from a previous fall on October 29, 2025. A Med-Tech contacted (R1's) health care provider around 9:00 am to inform of the bleeding and was advised to apply pressure to control the bleeding. At 9:33 am, the Med-Tech called the health care provider back to advise that the bleeding from the wound was not able to be controlled, and (R1) stated they were feeling light-headed. The facility was advised to send (R1) to the Emergency Room and a medical transport arrived at 10:05 am. (R1) returned to the community later the same day and with no new orders. The RCC stated (R1) has the habit of picking their wound and since this incident, staff have placed a wrap around (R1's) head to deter resident from picking the wound. Staff will also try and redirect (R1) if they are observed to be picking at the wound and they will continue to provide first aid care. The administrator stated (R1's) wound is healing well.

LPA and RCC discussed a recent fall for resident (R2) with the hospice nurse who was present. (R2) fell on November 22, 2025 (12:50 pm) out of bed onto the floor and was bleeding from their nose and mouth. Staff immediately contacted the hospice company and was not able to speak to a nurse until 1:30 pm, at which time hospice staff advised that (R2) be sent to the emergency room. Discharge papers show (R2) was treated for a fall and a "comminuted fracture of nasal bone". cont on 809C-1..