Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection and met with Nekia Xavier, Health and Wellness Director, and Mike Talani, Administrator. LPA explained the purpose of the inspection was to deliver findings for an investigation the Department's Investigative Bureau (IB) conducted regarding the non-hospice death of (R1) in May 2025.

During the course of the investigation, the Department interviewed multiple facility staff, residents and reviewed extensive documentation, including hospital medical records, facility physician's reports, care plans, the incident report (LIC624), and charting notes for (R1). The results of the investigation are as follows:

Resident (R1) was found on the ground in their room on May 17, 2025, (0808 hours) during morning rounds, and appeared confused and complained of pain in their shoulders. Staff called 9-1-1 and resident was sent out for further medical treatment as having a possible stroke. (R1's) urinalysis revealed a possible infection and (R1) was admitted to the Intensive Care Unit (ICU) with a diagnosis of septic shock, secondary to Urinary Tract Infection (UTI). (R1) passed on May 17, 2025 (1937 hours), and their immediate cause of death is noted as septic shock , with an underlying cause of a Urinary Tract Infection (UTI).

Multiple facility residents were interviewed and did not express any significant concerns about their health or safety living at the facility. During staff interviews, it was revealed that (R1)had a history of migraines; however, facility staff indicated they had no prior knowledge of (R1) having frequent UTI's and (R1) did not show any signs/symptoms for this prior to being hospitalized. Staff and facility documentation shows that (R1) was independent of services, had meals delivered to their room, and there were no significant changes in (R1's) condition leading up to the fall, including any signs of a UTI. The Health and Wellness Director stated (R1's) only symptom, before being sent to the hospital, was a headache/migraine, which was a chronic issue. *cont on 809C-1...