Follow-up·September 16, 2022

On 9/16/2022 at 9:00AM, Licensing Program Analysts (LPAs) G. Luk and P. Watson arrived unannounced to conduct a Case Management visit in regards to death report received on 9/9/2022. LPAs met with caregiver, Nenita Manuel. LPAs spoke with Administrator, Arnold Soleta over the phone and was unable to be at the facility. LPAs received death report on 9/9/2022 for resident (R1). Death report stated that resident was found unresponsive and staff called 911. Paramedics arrived and pronounced death. LPAs interviewed staff who stated that R1 was on palliative care. On 9/9/2022, staff (S1) went into R1's room at around 7AM and cover R1 with blanket. S1 stated R1 was sleeping and didn't want to wake R1 up at 7AM. When S1 tried to wake R1 up at around 8:50AM, R1 was unresponsive and called 911. Record review showed that R1 had a diagnosis of renal failure and was on dialysis for 8 years. R1 had a DNR. While LPAs was at the facility reviewing information regarding the death report, R2 was upset and had a behavior. LPAs have staff called R2's family member and confirmed that R2 recently moved to the facility. R2 is still adjusting to living at the facility. LPAs advise administrator to following up with R2's family and doctor regarding R2. Exit interview conducted. A copy of this report provided.