Incident investigation·February 25, 2022

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to Community Care Licensing on 02/24/2022. LPA was greeted and granted entry into the facility by Executive Director Carrie Galloway and explained the reason for the visit. Death report dated 02/23/2022 indicated Resident 1(R1) was found outside the resident's room around 1 AM on 02/22/2022 after pushing the pendant for assistance. R1 was confused and disoriented. R1 was assessed and had low oxygen saturation. R1 agreed for medical intervention and 911 was called. Paramedics responded and R1 became unresponsive on the stretcher. CPR was initially started but then stopped due to resident having a "Do not resuscitate" on file. Resident was pronounced dead at 2:19 AM. During the visit, LPA toured the facility and interviewed Executive Director as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Per physician report dated 09/11/2019, R1 has a diagnosis of Type 2 Diabetes, Essential Hypertension, Hyperlipidemia, Unspecified Depressive Disorder, Benign Neoplasm of Prostate and Benign Prostatic Hyperplasia. Facility to provide a copy of death certificate to LPA upon receipt. Exit interview conducted and a copy of this report was left at the facility.