Incident investigation·March 26, 2025

On 3/26/2025, at 10:13am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a case management visit. LPA met with Paulette Cameron, staff on duty (S1), and stated the purpose of this visit. S1 notified the facility supervisor Renae Earl of this visit and spoke with LPA over the phone. Renae is unable to come to the facility at this time and permitted S1 to sign this report. Present during today’s visit were 3 residents in care with 1 staff on duty. The purpose of this visit is to follow up on the submitted death report for Resident_1(R1) occurred on 9/10/24. Death report stated that R1 had passed away as a result of aspiration while eating dinner. The investigation into R1’s death consisted of interviews and record reviews. Review of R1’s death certificate confirms that R1 passed away on 9/10/24 due to cardiac arrest with dementia listed as a contributing condition. Other health issues were also noted including chronic diastolic heart failure. The time interval between the onset of cardiac arrest and death is recorded in minutes. No biopsy or autopsy was performed. A review of R1’s Coroner’s Report revealed that on 9/10/24, the responding deputy arrived and confirmed Cardiac Pulmonary Resuscitation (CPR) had been performed on R1 and continued by emergency personnel. Epinephrine and shocks were also administered, and intubation was attempted. All were not successful. It was also noted that R1 was struggling with eating dinner prior to death. Emergency services was summoned when R1’s condition worsen. Additionally, it was confirmed that R1 was not receiving hospice services. Based on the investigation, both death certificate and coroner’s report did not indicate R1’s death was questionable. {1 of 2} During this visit, LPA was informed by S1 that one of the current resident in care (R2) has bedridden status. Through interview, S1 explained to LPA that R2 does not get out of bed independently and that R2 is in bed all day. However, S1 noted that R2 can turn or reposition. During this visit, an outside agency staff (S2) arrived to visited R2. Through interview with S2, R2 is unable to independently reposition in bed or turn without assistance. Per observation, R2 is in the master's bedroom located near the fireplace at the living room area. According to the facility's license, bedroom #3 was approved for bedridden. Per review of R2's medical assessment (LIC602A) dated 9/13/2024 indicated that R2 is non-ambulatory which is counter indicative of what was noted through interview with S1 and S2. Per review of R2's admission agreement indicated that R2 was admitted to this facility on 9/9/2024. Following a discussion with Renae, it was noted that when R2 was admitted, they were nonambulatory status and R2's health gradually declined since then. LPA provided advisory that R2 be reassessed by their physician to ensure their ambulatory status is accurately documented. During this visit, LPA obtained copy of relevant documents relating to R2 for review. LPA will conduct a facility file review to confirm which is bedroom #3. LPA will follow up with the facility staff regarding updates on R2's ambulatory status. Exit interview was conducted with Renae over the phone and a copy of this report was provided. {2 of 2}