Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20251001111956 . During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA is also following up on an incident report received on 10/16/2025. LPA met with Acting Director of Health Services Scott Self

Wile investigating the complaint 26-AS-20251001111956, regarding R1, LPA noted issues in resident R1's Care plan.

The Department reviewed resident R1’s Progress notes. Progress note dated August 7, 2025 states around 2:30pm, R1 had an unwitnessed fall in his/her bathroom. R1 claimed he/she slipped when trying to use his/her toilet. R1 was able to move all extremities without pain, no complaints of pain, no visible bruises.

Progress note dated September 27, 2025, R1 had an unwitnessed fall around 1:40pm. Staff brought resident to his/her room to rest on recliner, then 10 minutes later, a thud was heard. Staff checked on R1 and found him/her next to recliner. Resident was assisted, and no injuries noted.

On October 6, 2025, the Department received an incident report regarding R1, dated September 27, 2025. The incident report stated, on September 27, 2025, around 1:40pm, R1 was found sitting on the floor next to his/her chair. R1 stated he/she lost his/her balance and fell. Hospice noticed a small lump on the right side of head. R1 denies pain. R1’s POA was notified and stated he/she didn’t want R1 to be sent to the hospital.