Incident investigation·November 7, 2024

On 11/07/2024 at 3:40 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding a death that was reported to Community Care Licensing Division (CCLD) on 08/16/2024. LPA met with General Manager, Linda L. Fisher and explained the purpose of the visit. GM, Linda L. Fisher, had to leave and authorized Health Services Director, Davinderjit Singh, to sign the report. On 08/16/2024 CCLD received a Death Report (LIC624A) that a caregiver found R1 laying on the floor by their bed. The report indicated that R1 was last seen by a Med Tech at around 11:15 AM and was reminded about lunch on 08/16/2024. LPA interviewed S1 and they stated that the caregiver found R1 laying on the floor and that R1 was not breathing. S1 stated that 911 was called and the paramedics and police arrived. S1 stated that the paramedics arrived and assessed R1 but there was no sign of life. The LIC624A further indicated that paramedics pronounced R1 deceased on 08/16/2024 at approximately 12:30 PM. The LIC624A further indicated that R1 had a Do Not Resuscitate (DNR) on file. Police Officer investigated and called the coroner to remove the remains. Police Report #24-2378. LPA reviewed and obtained a copy of R1's physician's report. LPA requested a copy of death certificate to be submitted to CCLD. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.