Facility Evaluation Report

On 2/13/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced for a case management deficiency visit. LPA Tamayo met with Licensee, Magie Quirez, and (S1) explained the purpose of the visit. The Administrator, Grace Quirez, was not present during this visit.

Allegation: Resident did not receive timely medical attention

During the course of a self reported incident, the Department found that a resident did not receive timely medical attention.

Per Incident report dated 8/31/25 the Regional Office was notified that Alpha 1 was activated by the licensee on 8/28/25 for Resident 1 (R1), as they were sent to the Hospital on 8/28/25 due to swelling in the right side of R1’s face and “blisters burst the back of both legs”.

A Death report for R1 was sent to the Regional Office by the Licensee on 9/4/25, in which it was indicating R1 died on 9/1/25 due to a bacterial infection. Per R1’s Death Certificate for R1, it was revealed that the primary cause of death was septic shock with Stage 4 pressure ulcers. On 9/4/25, LPA Tamayo called S1 and provided additional guidance regarding completing incident reports and death reports and requested the and the LIC 602 and LIC 624 for R1. Record review indicates that Resident 1 (R1) was not on Hospice.

Hospital personnel (W1) explained that the pressure injuries could have developed over the course of a few days, but not in a single day.