Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection after reviewing hospice records for resident (R1), who passed in March 2026. LPA met with Janeyn Kelly, Administrator, and explained the purpose of the inspection. Also present were staff, Jhamil Espino, Jacob Espino and Hazel Polig.

LPA reviewed multiple pages of hospice records from when (R1) was admitted to service on February 20, 2026 through their passing on March 4, 2026. Paperwork showed that (R1) had an admitting hospice diagnosis of Gastrointestinal Hemorrhage and a related diagnosis of total body rash, Bi-lateral edema, and jaundice. The hospice notes state the the hospice nurse reviewed medications with (R1's) family member and collaborated with the facility administrator on the plan of care. On February 20, 2026, (R1) stated they had no pain, but itching from the rash, and difficulty seeing and hearing. The notes also state (R1) was observed to have a healing cut on their head from a fall, and sutures were removed recently. The hospice Plan of Care requires (R1) be placed on bedrest and receives care for incontinence/catheter.

The hospice notes reflect that various hospice personnel visited (R1), multiple times a week and the facility was advised to continue monitoring (R1) for proper positioning, skin measures, bowel/urinary incontinence regimen, pain management, pain assessment and fall risk assessment. (R1) had an unwitnessed fall on February 28,2026 (8:30 am) and sustained abrasions on both legs. Hospice staff promptly applied wound care and conducted a neurologic assessment. Notes say (R1) did not have a loss of consciousness or mental status change. Facility staff was advised to continue monitoring (R1) and contact hospice immediately if (R1) begins to show any signs/symptoms such as headache, fever, vomiting, confusion, seizures, vision changes, or bleeding. Facility staff was also provided with education and support to monitor for signs of pain to administer medication needed. *report continued on 809C-..