Facility Evaluation Report

Licensing Program Analyst (LPA) Javina George conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by Direct Support staff Nicole Carpenter. LPA explained the purpose of the visit and met with Nicole. Administrator was available by telephone. The visit is in response to the death of Resident #1 (R1), whom passed away on 1/9/2022.

During LPA's visit, LPA reviewed R1's file and obtained copies of the following: ID/emergency Information form, admission agreement, Physician's reports, resident pre admission appraisal, progress notes, medication records (MARs), Personal property records, weight record, and laboratory paperwork. Additionally, LPA requested a copy of R1s death certificate when it is made available.

During today's visit no deficiencies were cited in regards to this incident.

An exit interview was conducted, and a copy of this report was provided to Nicole Carpenter.