Facility Evaluation Report

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to the facility to follow up on information obtained during the investigation of the death of Resident 1 (R1). LPA met with Administrator Jones Ntekim.

During the Department’s investigation of R1’s death, it was discovered that staff failed to perform hourly check’s on R1 during the afternoon of February 15, 2022. Facility Room Check logs obtained by the Department revealed facility staff did not perform room checks on R1 at 2:00pm, 4:00pm, 5:00pm, 6:00pm and 7:00pm. In addition, facility video footage show staff conducted a room check at 5:05pm but did not return until 7:22pm. Per interviews with staff, resident room checks are to be completed every hour and are to be documented on the Facility Room Check logs.

Based upon the above stated information it was determined that facility staff failed to provide the care and supervision necessary to meet the resident’s needs. In accordance with Title 22 regulations a citation is being issued as detailed on the LIC809D.

An exit interview was conducted and a copy of this report, along with Appeal Rights was reviewed with and provided to Administrator Jones Ntekim.