complaint·February 19, 2025

Records also indicate that W1 observed R1 lean back in R1’s room chair after dinner and W1 began to prepare dessert in the kitchen. When W1 returned to R1’s room, W1 noticed R1 was pale and unresponsive. W1 made a phone call, pressed the call button, received a call, and then called 911. Interview with the facility’s nurse (S2) indicated that S2 assessed the situation, placed R1 on the floor, and started performing CPR until the paramedics arrived. The death report revealed the following: R1 passed away on 01/09/25 7:01 PM in R1’s apartment; Paramedics determined airway obstruction – food blockage – was the immediate cause of death; At 6:22 PM, R1 was assisted to lying position, CPR initiated, law enforcement contacted, and staff remained with resident; Paramedics and police arrived and called time of death at 7:01 PM. Regarding the allegation “Questionable Death," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: "Facility staff failed to seek timely medical attention,” for Resident #1 (R1). Department records indicated that R1 had a private caregiver (W1) who is employed by an outside home care organization. W1 was present during the incident. Records also indicate that W1 noticed R1 was pale and unresponsive. W1 called Witness #2 for guidance, pressed the facility’s call button several times, received a call from Witness #3, and then called 911. Department records also indicated that W1 pressed all three buttons. LPA observed that the call system in residents’ room include three buttons. Interview with the Executive Director (S1) and staff indicated that one of the three buttons is selected to clear the call. Interview with the facility’s nurse (S2) indicated that R1’s family called the lobby and the message was relayed to nursing station. S2 indicated that upon arrival to R1’s room, S2 assessed the situation and performed CPR until the paramedics arrived. Five out of six resident interviews indicated that staff provides timely medical attention. Five out of six staff interviews indicated that staff responds to a call button within five to ten minutes. Continue to LIC9099-C. Regarding the allegation “Facility staff failed to seek timely medical attention,” based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director Keith McGenva.