Incident investigation·September 18, 2025

On 9/18/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to correct a report that had been mistakenly entered for a different facility. During a previous unannounced visit to this facility on 8/19/2025, the report had been submitted under Facility #032701225, which has a similar name. LPA met with the facility supervisor, Renae Earl (S2), and clarified the purpose of the visit. *** The report below was incorrectly entered to a different facility *** Licensing Program Analyst (LPA) Arvin Villanueva arrived at the facility unannounced to follow up on a death of a resident in care. LPA met with staff on duty, Lacreisha Wilson (S1) and explained the reason for the visit. The Licensee, Chukwudi (Patrick) Ikiseh, was notified and gave permission to S1 to sign this report. Initial observation: Upon arrival, LPA observed (S1) leaving the facility to go to another facility, about two houses away. LPA rang the door bell 3 times before a visitor (V1) answered the door. V1 stated they cannot let LPA come in and stated that the staff on duty had stepped outside for phone call. After 2 to 3 minutes later, S1 arrived back to the facility and LPA was able to enter. LPA observed 4 residents in the living room with V1 visiting a family member. Per interview with S1, S1 was instructed by their supervisor (S2) to go to the other facility down the street to open a door for the delivery person. S1 confirmed that the visitor is not a staff and that no other staff is on duty during this visit. LPA spoke with Licensee, Chukwudi (Patrick) Ikiseh, to inform him of the lack of staff upon arrival. Per Licensee, he was observing the residents through the camera in the living room. {1} Regarding the death incident: On December 2, 2024, the facility notified the Department of the death of Resident 1 (R1). Upon notification of the death, the LPA requested and obtained copies of resident and staff records, including but not limited to staff schedule, resident roster, Personnel Report, Physician reports and Needs and Services Plans for residents. In addition to the records already noted, the Department obtained medical records from the acute hospital, interviewed staff, reviewed notes from doctor visits for Resident 1 (R1), and reviewed medical records from the skilled nursing facility R1 was admitted. Per medical records, it was noted that R1 had a catheter in place. R1 was responsible for the care of the catheter including draining. R1 was independent with most activities of daily living only receiving staff assistance with showers and catheter bag sanitization. R1 was routinely seen by their urologist who did not note any concerns regarding the catheter. Per staff interviews, blood was observed on 11/4/2024 in R1’s catheter bag. Paramedics were called to assess R1, but R1 refused medical treatment. Blood was observed in the catheter bag again on 11/15/2024 and paramedics called. R1 was treated at the hospital and died on 11/20/24. The Department also reviewed local fire department records to confirm emergency services were called on 11/4/24 and 11/15/2024. It was unclear if the death of R1 was due to neglect of the facility or R1’s own negligence, therefore the allegation was unsubstantiated. *** end of report *** Note that deficiency was cited on 8/19/2025 and facility submitted the plan of corrections. S2 needed to leave during the visit and gave permission to S1 to sign this report. Exit interview was conducted and a copy of this report was provided. {2}