Facility Evaluation Report

On 4-30-2025 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a case management previously conducted on 4-11-2025. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. During this case management investigation, LPA conducted interviews with Administrator and Staff1 (S1). Additionally, LPA reviewed facility file documentation including physician reports for resident1 (R1), R2, R3, and R4, death report dated 12-28-24, and death certificate pertaining to R1. Additionally, LPA reviewed hospital discharge paperwork. Investigation has determined that R1 passed away on 12-28-2024 with death certificate noting cause of death as acute hypoxemic respiratory failure and aspiration pneumonia. Cause of death was also revealed through hospital discharge paperwork. It was further determined through this case management investigation that staff's actions while on duty did not result in R1 at risk for the above cause of death which was deemed natural causes.

Additional reviews of facility file documentation and staff interviews determined that facility currently provides care for multiple residents with dementia including R2 who is determined to be a wandering and elopement risk. During today's visit, LPA observed R2 attempting to elope from facility. It was further determined that R2 has a history of attempting to elope at various times throughout the day resulting in an on-going risk for elopement. Facility staffing review and interview determined that one staff was on duty for four clients in care including a resident with elopement risk. Additionally, it was determined through observation that facility is not utilizing a staff alert or auditory device to monitor exits on exterior doors.

As a result of today's case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.