Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. The purpose of this visit is to deliver the final report on a case management that was initiated on 09/19/2025 regarding a death report received on 08/12/2025 for former resident (R1). LPA met with General Manager, Ida Gemignani-Stearns.

On 08/12/2025, the Department received a death report stating that on 08/11/2025 at approximately 09:30am, a staff went to give R1 medications and found R1 unresponsive. In the report, it was stated that the resident was noted to have some confusion on 08/08/2025 and 911 was called but resident refused to be transferred for further evaluation.

4 staff members were interviewed. Based on staff interview, R1 was not under hospice care and resided in assisted living. R1 was only receiving medication management and housekeeping once a week but was independent for other care needs. According to the staff, the last time R1 was checked was during the night before his/her passing during bedtime medication pass. Since R1 wasn't a resident who required care, staff were not required to check R1 throughout the night unless R1 called for assistance. Staff members who observed R1 that night before his/her passing did not report anything unusual with R1’s condition.

R1’s responsible party was interviewed. Based on the interview, it was stated that R1 had many health conditions which may have contributed to his/her passing. It was stated that leading up to R1’s passing, R1 was already not feeling well but refused to go to the hospital. Page 1 of 2.