Facility Evaluation Report

05/07/2026 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Licensee Nora Serrano. Today’s visit is regarding an incident that occurred on 03/19/2026.

It was reported that on 03/19/2026 in the morning, Client 1 (C1) was vomiting and reported not feeling well. Staff immediately planned to take him to a walk-in clinic but determined he appeared too ill and took C1 to the local ER where C1 was diagnosed with very low potassium. The hospital performed blood work, a urine test, and an EKG. C1 was treated for nausea and vomiting and was administered potassium chloride via IV. C1 was expected to remain at the hospital until his treatment was completed and further test results determined whether he could be released or required an overnight stay. C1 chose to discontinue treatment and removed his IV. Despite the nurse informing C1 that refusing treatment could result in hospitalization again, C1 refused to continue. C1 then left the hospital. Staff followed C1 and encouraged them to return to the ER for treatment, but they insisted on going home. Staff accompanied C1 home.

During the course of the investigation, it was learned that the licensee took C1 to the walk in clinic on 03/20/2026 so they could read the blood test results that were obtained during the ER visit on 03/19/2026. The physician prescribed potassium pills for C1. Since this incident C1 has not had any additional issues with low potassium. C1 tends to make poor dietary choices that cause C1 to suffer from bouts of diarrhea and behavioral incontinence.

In order to prevent this from happening again the facility modified C1’s diet to include more fruits and vegetables that contain potassium.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to licensee Nora Serrano.