Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Case Management Visit to follow up on a Death Report received on 12/27/2023. LPA was met by Administrator Denise Hornal and explained the purpose of the visit.

As noted on the Death Report on 12/27/2023, Client #1 (C1) was found on the floor of their bedroom at approximately 4:30 AM on 12/27/2023 by a staff member, and was pronounced deceased at 5:05 AM.

During the course of the visit, LPA interviewed Administrator Denise Hornal, along with Staff #2 - 3 (S2 - S3). Denise along with S2 - S3 explained that in the week leading up to C1's passing, C1 displayed increasing signs of confusion and disorientation, and also displayed a deterioration in their eating skills. These symptoms prompted the facility to schedule a doctor's appointment for C1 in order to obtain a referral for a neurological evaluation on 12/26/2023. On the evening of 12/26/2023, staff helped C1 to bed after dinner and providing C1 with their evening medications. C1 was last observed in bed at 3:30 AM by S4 who checked on C1 every 2 hours. At 4:30 AM, S4 found C1 unresponsive on the floor in their bedroom. Paramedics along with the police were called afterwards and arrived on the scene.

LPA obtained and reviewed the most recent Physician's Report, Death Report (LIC624A), Individualized Program Plan (IPP), Emergency Contact and Information Sheet, and the Medication Administration Records (MARs) for the months of October, November, and December of 2023. LPA also conducted a tour of the facility including C1's bedroom, the kitchen, living room, food supply, and observed that sharp objects are kept locked and secured. Administrator will submit the Death Certificate once it is obtained.

No deficiencies observed during today's visit. Exit interview help and a copy of the report was provided to the facility.