Facility Evaluation Report

On 09/11/25, LPA Steve Chang and LPM Romeo Manzano conducted an unannounced Case Management Visit-Incident during a complaint investigation.

On 08/08/25, the Department received a self-reported unusual incident and death reports that on 7/25/25, a resident (referred as R1) was sent to ER by home health nurse to check on R1's Foley Catheter due to R1 expressed a significant discomfort and pain level of 8/10. R1 was taken to the hospital due to infection and died on 08/02.

On 09/09/25, LPA/LPM interviewed S3. S3 stated that R1 was sent to ER via ambulance on 07/25 due to Home Health Nurse (HHN) was unable to replace R1's Foley catheter during visit. S3 stated HHN came to see R1 after staff reported of possible infection.

During today's inspection visit, LPA and LPM toured the facility. LPA and LPM met with resident (referred as R2) in bedroom#2. R2 was observed naked in bed wearing a undergarment. R2 noted to have long toenails on both feet. ADM stated that R1 does not have medical insurance but being visited with HHN; however, ADM did not consult a podiatrist, nor there is no appraisal about R2's feet and his/her behavior of being naked. R2's medication was also observed on R2's side table accessible, unlocked Staff (referred as S1) stated that he/she forgot to locked it after he/she administered medication. Two other medications were also observed accessible in the dining area, 2 medicines belongs to R3.