Facility Evaluation Report

**Report amended- a deficiency was removed due to incorrect CCR. Deficiency re-issued 2/13/25.**

On 1/14/25, Licensing Program Analyst (LPA) Kevin Mknelly, arrived to deliver incident investigation findings and met with Executive Director.

On 5/3/24, while LPA was present to investigate facility reported elopement by R1, on 4/20/24, LPA was notified of R1’s unexpected death on 5/2/24. LPA returned on 5/16/24 to conduct further investigation. LPA requested records related to R1 and conducted staff interviews.

Records review for R1 found that R1 sustained a Subdural Hematoma on 1/1/24 following an unwitnessed fall at the facility. Following hospitalization for the injury, Hospice care was initiated on 1/7/24. R1 was also diagnosed to have dementia and documented as a fall risk. Hospice records included recommendation that R1 has standby assist while ambulating.

Hospice records stated that on 5/1/24, R1 had a unwitnessed fall from R1’s bed to a fall mat. No injury, pain or agitation was observed at the time of the fall. Medication Technician (Med Tech) S1 reported to Hospice that the fall occurred approximately 1 hour after morning medications. Based on R1’s medication list, the medications R1 was administered included 0.5 mg of Lorazepam (Ativan) , Metroprlol 10 mg, Quetiapine (Seroquel) 50 mg. The administered medications given list possible side effects of drowsiness, dizziness or unsteadiness.

On 5/1/24, S1 reported to the Hospice nurse that since R1’s increased current doses of Lorazepam and Quetiapine on 4/26/24, R1 was observed to be sleeping approximately 15 hours per day. Per Hospice records, the reason for Lorezepam listed was for R1’s anxiety and Quetiapine for agitation, restlessness and exit seeking.