Facility Evaluation Report

On April 02, 2025, at 10:30 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding a death report for Resident (R1) that was received by the department on March 25, 2025. Upon arrival, the LPA was greeted by the Executive Director (ED), Flavio Silva. The LPA disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 88.

According to R1’s Death Report, R1 had a fall at the facility on 03-18-2025 and was transported to the hospital, but the Licensing department had not received an Unusual Incident Report for R1’s fall and subsequent admission to the hospital.

ED provided a copy of the Unusual Incident Report to the LPA for R1’s fall on 03-18-2025 and a copy of the fax transmittal page that showed the Unusual Incident Report was successfully faxed to the Licensing department on 03-18-2025 at 4:01 PM.

ED stated that R1 had a fall on 03-18-2025 and a caregiver found R1 on the floor inside R1’s room in front of a chair. Care staff asked R1 if they could get up. R1 stated that they could not get up and said they were in pain. 911 was called and R1 was transported to the hospital. R1’s family and primary care physician (PCP) were notified.

ED further stated that R1 was not necessarily a fall risk, and prior to the fall on 03-18-2025, R1 had been falling on and off. However, there was never a need to call 911 since R1 had been able to get up and had not reported any pain.