Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Susan O'Shaugnessy.

Facility internal incident reports and progress notes, combined with hospice visit records and interviews of managers and outside sources, aligned to show: Resident #1’s (R1’s) terminal/admitting hospice diagnoses were “unspecified severe protein-calorie malnutrition” and “Alzheimer’s disease with late onset.” [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] R1 had an unwitnessed fall inside their bedroom on the evening of 03/31/2026, after which facility staff phoned R1’s responsible person (RP) and hospice agency. Per hospice notes, facility staff reported to hospice personnel that R1’s left elbow following the fall had redness, swelling, and pain with movement. A hospice nurse visited and assessed R1 that same evening, writing, “[R1’s] left elbow noted to be significantly swollen, red, warm to touch, and tender compared to right elbow…pain evidenced by grimacing and guarding left elbow.” The hospice nurse stated to facility staff that they believed R1’s left arm to have a fracture and recommended that R1 be sent to the hospital. However, R1’s responsible person did not want R1 sent to the hospital.

Licensee deferred to the RP and did not call 911 for R1, which is still required when there is a medical emergency not directly related to the expected course of the resident’s terminal illness. (Per regulation, Licensees are required to call 911 in these situations. If a resident and their RP still refuse transport to the hospital, then they should do so directly to the first responders, after those first responders have evaluated the resident on scene and provided their own recommendations). [CONTINUED ON LIC 809-C]