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25 | On 11/7/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of closing an investigation conducted by the Department in regard to a self reported unusual incident report dated 4/21/2024. The incident report indicates that on 4/18/2024, staff checked on resident (R1) in their apartment, finding R1 laying on the floor with a plastic bag over (their) head, tied around (their) neck. Staff determined the resident was unresponsive. According to incident report, the hospice agency was called and then hospice instructed to call 911 due to the “unnatural death.”
The Department has reviewed and gathered relevant records including facility incident reports, resident R1 needs & service plans, physician’s reports, daily chart notes and medical records related to this incident and determined the following: On 3/28/2024, R1 had indicated to their family and the facility a refusal to eat and additionally made statements of ending R1’s own life. R1’s family and the facility contacted 911 with R1 sent out for medical attention due to physical pain and suicidal statements. An updated care assessment for R1 had been completed on 3/25/2024 prior to this incident. No further care assessments were conducted after 3/28/2024 when R1 was sent out for medical assessment, or after 3/29/2024 upon R1’s return to the facility. There are no indications of increased status checks or assigning one-on-one care for R1 for preventative measures documented.
Based upon the Department’s conducted interview and information gathered with the Health Service Director (S1) the following is indicated: S1 is a Licensed Vocational Nurse (LVN) at Ivy Park. S1 duties are to oversee the care staff, conduct assessments for new and existing residents, review resident’s medication, administer medication to residents, deal with family and resident concerns, and train care staff and medical techs. S1 continues, residents are checked on every one to two hours unless the service plans states that there should be more checks. Staff will not check on a resident if the resident does not want to be checked on. Residents are given an alert pendent when they first arrive at the facility.
Continued onto LIC809-C |
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32 | The pendent allows the resident to call for help when they need it. There are no logs kept when a resident is checked on. When a new resident is admitted to the facility, S1 will conduct an assessment on the resident before they move in. The assessment is done to see what assistance the resident may need with their Activities of Daily Living (ADL) and their mental health status. S1 updates the service plans when a resident has a change in condition.
The Department interview with S1 continued regarding R1 level of care and supervision and observations leading to R1’s death. This revealed that S1 was aware of the repeated suicidal statements made by R1 to staff and the hospice nurse. Although S1 admitted they were aware of the change of condition, S1 failed to complete a reappraisal for change in resident’s status and the need for increase status checks of R1 after repeated suicidal statements. S1 additionally indicated that residents are to receive one-on-one after indicating suicidal ideations. S1 however failed to ensure one-on-one care was provided for R1. Lastly, S1 admitted that they should have been more “on top of” R1s situation, provided more frequent checks, and provided R1 additional resources.
Based upon the Department’s conducted interview and information gathered with the Executive Director (S2) the following is indicated: S2’s duties are to oversee the facility, manage the lead staff, work on the facilities’ financial, sign off on payroll for the facility, work with the facility nursing director, and approve and review incident reports. S2 continues, residents are checked on one time per shift. Caregivers can check on residents anytime during their shift as long as the resident is checked on before the end of the shift. Residents can refuse to be checked on. Residents are also given an alert pendant that they can press if they need assistance at any point in time when they have an emergency. No log is kept when a resident is checked on. When the facility accepts a new resident, an assessment completed by Health Service Director (S1) to determine the resident needs before they move into the facility. S1 also conducts a mental health evaluation to see if the resident requires memory care. The assessment is also performed to see if the resident is a fit for assisted living or memory care. S1 then reports to the care team what the new resident’s needs and level of care. After the initial assessment is performed, a second assessment is completed two weeks later to see how the resident is adjusting to the facility and determine any updated needs. A reassessment is performed every six months or when a resident has a change of condition. The facility considers a change of condition when there is a change in the resident’s baseline behavior or mental health status.
Continued onto LIC899-C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |  |
Request Denied
Type A
11/08/2024
Section Cited
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7 | 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities - (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidence by: Based upon interviews with Health Service Director and Executive Director and review of resident (R1) records it was found that | | | |
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14 | the facility identified a need for R1’s change in level of care due to suicidal ideations. However, Executive Director and Health Service Director failed to provide care and services to meet R1’s needs, resulting in severe injury/death by means of suicide. This is an immediate health and safety & personal rights risk to residents in care. | 8
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14 | In addition, continuous training is implemented for suicide prevention and personal rights of residents. Lastly, S1 is no longer working for the facility.
IMMEDIATE CIVIL PENALTY OF $500 WAS ASSESSED FOR VIOLATION RESULTING IN SICKNESS OR INJURY TO A RESIDENT IN CARE. | |
Request Denied
Type A
11/08/2024
Section Cited
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7 | 87466 Observation of the Resident: Licensee shall ensure that residents are...observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes...or deterioration of mental ability or a physical health condition are observed, licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & responsible person, if any.." This was not met as evidence by: Based upon interviews with | | | |
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14 | Health Service Director (S1) and Executive Director (S2) and review of resident’s (R1) records, it was found that the facility observed and were aware of R1’s suicidal statements and change of condition, indicated on 3/28/2024 and on 4/18/2024, but failed to ensure appropriate changes to R1’s level of care was initiated or documented, leading to severe injury/death of R1. This is an immediate health & safety risk to residents in care. | 8
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14 | In addition, continuous training is implemented for suicide prevention and personal rights of residents. Lastly, S1 is no longer working for the facility.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) | |
Request Denied
Type A
11/08/2024
Section Cited
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7 | 87463(a) Reappraisals – (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to..” | | | |
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14 | This was not met as evidence by: Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident (R1) documents, it was found that the S1 identified a need for R1’s change in level of care due to suicidal ideations and hospital visit on 3/28/2024. However, Health Service Director (S1) failed to develop and document an updated care plan to address R1’s suicidal ideations and increased supervision, leading to the severe injury/death of R1. This is an immediate health & safety risk to residents in care. | 8
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14 | Licensee has implemented multiple regional staff now serving as Resident Service Director ensuring compliance for appraisals and reappraisals. Deficiency cleared. | |
Deficiency Dismissed
Type A
11/08/2024
Section Cited
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7 | This is an amendment to original report date of 11/7/2024 to identify corrected regulation section: 87405(a) The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This was not met as evidence by: | | | |
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14 | Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident (R1) documents it was found that S2 failed to ensure frequent checks on R1 was done as recommended, that R1's appraisal was updated including suicidal ideations with updated staffing plan, and that R1 is performing their duties, which is ultimately the responsibility of S2. | 8
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