Incident investigation·March 27, 2025

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent case management visit in response to an initial case management dated 1/24/2025 following the death of Resident #1 (R1) that occurred at the facility after R1 choked during their meal on 12/31/2024. During the initial visit, LPA obtained R1's FACE Sheet, Most Recent Physician's Report, a meal menu for the week of 12-29/2024 - 1/4/2025, their medication orders, and also interviewed Staff #1 (S1). Since the initial case management visit was conducted, Investigations Branch (IB) investigator Christine Ferris conducted her own investigation including a visit to the facility on 2/3/2025 which involved interviewing residents, staff, and obtaining the death certificate of R1. During today's visit, LPA will deliver the findings of the investigation. During IB's investigation, IB interviewed the staff and residents who were present at the time that R1 passed away. R1 had a mechanical soft or "chopped" diet as ordered by their physician, which they received for lunch on 12/31/2024. When R1 began to choke, all residents and staff interviewed explained that staff responded quickly and appropriately to the incident, including initiating CPR and calling emergency services. Residents who witnessed the incident said R1's meal was indeed "chopped." Neither staff nor residents shared any information to indicate the incident could have been prevented. The Death Certificate of R1 states that the cause of death was "Upper Airway Obstruction - Food Bolus Complicating Neurological Impairment." Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.