Incident investigation·August 11, 2025

On 08/08/25 while at the facility for another reason, LPA D Panlilio conducted an unannounced case management visit and met with staff (ED, DN). LPA explained the purpose of the visit with staff. At 3:30PM, LPA discussed the self reported incident report dated 08/04/25 with staff (ED, DN) where resident (R1) was found by staff on the floor face down with brownish fluid all over the floor around 3:23PM on 08/01/25. R1 was unresponsive and 911 was called. Staff was instructed to start CPR and when paramedics arrived, they took over. R1 was pronounced deceased by paramedics at 3:43PM. Director of Nursing (DN) stated that she talked to R1 around 1PM that day and he looked OK. DN will submit copy of death report to CCLD when available. LPA also discussed another incident regarding resident (R2) who managed to exit the facility without staff knowledge on 08/02/25 around 9:47PM. Antioch police called the facility and reported that R2 was found wandering the neighborhood and was sent to Sutter Delta hospital for evaluation. R2 safely returned back to the facility from the hospital with no injuries the same day. During visit, LPA observed R2 walking around the main hallway in good spirits and comfortable in his surroundings. He was observed well groomed and odor free. ED stated a new security code has been implemented for the exit door and increased monitoring of all residents. No deficiencies cited. Exit interview conducted and a copy of this report provided.