Facility Evaluation Report

On 5/7/25 at 2:00, Licensing Program Analysts (LPAs) Noel Wolf Petersen and Michael Bilger arrived unannounced at the facility to conduct a case management related to a recent death of a resident. LPAs were met by Direct Support Provider Amelie Diouf , and explained the purpose of the visit.

Based on review by the department regarding the death of Resident 1 (R1), it was determined that R1 passed away on 10/5/2024 at the facility. R1’s Death Certificate, indicated R1’s cause of death was due to deep vein thrombosis (DVT), kidney failure, and hypertension. R1 was seen multiple times at Acute Hospital Emergency Room on 10/2/2024 and on 10/3/2024. R1 was initially discharged on 10/2/2024 and prescribed medication to help R1’s DVT and prevent a pulmonary embolism from occurring as that could lead to death. In an interview with the department, Witness 1 (W1) recalled explaining to Staff 1(S1) the importance of giving R1 the medication after each ER visit. The medication logs obtained by the department investigator showed that R1 took the medication on 10/3/2024 and on 10/4/2024. In an interview the department, W1 stated that she was unable to determine that with or without the medication, R1’s death could or could not have been prevented. The investigation further determined through interview with W1, that R1 had several other health issues that could have contributed to her death. W1 felt that the three pills R1 took on 10/3/25 and 10/4/25 should have affected her DVT by improving and preventing any further blood clotting in her arms. W1 further explained in an interview with the department that there could have been multiple contributing factors into R1’s death.