Incident investigation·December 2, 2025

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced Case Management - Incident visit at the facility and met with the staff Limay De Leon, who granted access to the facility. The Administrator was contacted via a telephone and arrived at the facility at 10:20 AM. LPA explained the reason for the visit. On 11/24/2025 at approximately 11:24 AM, R1’s family visited and brought food for R1. R1 did not eat and reported symptoms including a dry cough, sore throat, difficulty swallowing, and chest pain. The family provided over-the-counter Mucinex (day/night). At approximately 12:50 PM, the family of R1 administered 20 mL of the Mucinex day-time dose to R1. After receiving the medication, R1 stated feeling better and expressed a desire to take a nap. At approximately 2:44 PM, the caregiver checked on R1 to provide lunch because R1 had skipped the meal. Upon entering the room, the caregiver found R1 unresponsive. The caregiver immediately notified the Administrator, who instructed the caregiver to call 9-1-1. Paramedics arrived at 2:46 PM and initiated CPR. CPR was subsequently discontinued after paramedics were informed that R1 had a Do Not Resuscitate (DNR) order on file. Per R1’s Primary Care Physician, R1 was pronounced deceased at 3:04 PM. LPA reviewed and obtained R1’s records and reviewed R1's medication. LPA observed that R1 had twelve (12) prescribed medications and nine (9) out of twelve (12) medications had discrepancies and was not given as prescribed. Continue on LIC 809C The Administrator reported that the cause of death was congestive heart failure and stated she would forward a copy of the death certificate to Licensing upon receipt. LPA determined that further investigation is required and will return at a later date to continue the inquiry. A deficiency was issued during today's visit. Appeal rights were explained. An exit interview was conducted, and a copy of the report was reviewed, signed, and provided.