Incident investigation·January 24, 2025

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced case management visit in response to Serious Incident Report (SIR) dated 1/2/2025 that describes the passing of Client #1 (C1). LPA met with Kathleen McDonald, Wellness Director for the facility, and explained the purpose of the visit. LPA Interviewed Staff #1 (S1) during the visit. LPA attempted to interview Staff #2 (S2), however they were not available. S1 explained on the day of the incident they were notified by other residents that C1 was choking and needed medical assistance. S1 observed that C1 could not speak and was struggling to breathe, and therefore began performing sets of Heimlich Maneuvers before beginning cardiopulmonary resuscitation (CPR). S1 stated that they began performing chest compressions on C1 as directed by the 911 operator, and S1 stated that they could not see any food in C1's throat when asked by the operator. Emergency Medical Technicians (EMT) arrived on the scene and took over chest compressions along with administering an Automatic External Defibrillator (AED) for 10 - 15 minutes until C1 was declared deceased. LPA obtained C1's FACE Sheet, Most Recent Physician's Report, a meal menu for the week of 12-29/2024 - 1/4/2025, and their medication orders. LPA attempted to obtain the resident's most recent appraisal, however there was none available on record. Deficiency was issue per Title 22, Division 6, Chapter 8, Article 8 and is cited on the LIC809D page. Exit interview was conducted and a copy of the appeal rights were provided.