Facility Evaluation Report

Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent case management visit for the death of Client #1 (C1) which occurred on 05/01/26. LPA met with Administrator Joey. The purpose of the visit was explained.

LPA Tao conducted the initial case management visit on 05/15/26. According to the Incident Report and Death Report dated 05/03/26, C1 passed away on 05/01/26 in the hospital after client fell on the floor at the facility on 04/28/26. The suspected cause of death was unknown. As stated in the Death Report, C1 fell due to missing a step and suddenly stumbled over C1’s walker which causing C1 falling forward onto the floor. Staff was in close proximity behind C1 and had reached out to assist C1 immediately. Additional staff and Administrator Joey came to support immediately. C1 was able to sit up transferring to a wheelchair and being responsive and coherent. Staff applied first aid to C1 right away and transported C1 to Huntington Memorial Hospital’s Emergency room for medical attention. Per C1’s CT scan, it showed C1 had a neck fracture. C1 stayed in the hospital and passed away on 05/01/26.

The facility provided a copy of the death certificate on 06/18/26. According to the Death Certificate, dated 05/23/26, C1’s primary cause of death was neck fracture. C1 has pre-existing condition. Per primary physician report, date 03/16/2026, C1 was diagnosed with osteoporosis. Based on the information obtained, there was no evidence the facility was neglectful or caused the death of C1.

There were no deficiencies issued during the visit. Exit interview was conducted with Administrator Joey. This report was provided.