Incident investigation·November 2, 2022

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a case management visit to follow up on a death report received by Community Care Licensing on 10/25/2022. LPA was greeted and granted entry into the facility by Caregiver Aris Jugo and explained the reason for the visit. Administrator Oana Abrudan arrived during the visit. Death report dated 10/23/2022 indicated 911 was called for Resident 1 (R1). Paramedics and OC Sheriff responded and resuscitation was initiated. R1 was declared deceased at the scene. Per facility staff, R1 was observed to have difficulty breathing and had a gray pallor. Staff initially thought the resident was choking and conducted procedure for choking. R1 was still responsive. The procedure did not work and 911 was called. In the interim, R1 was provided oxygen and was still responsive. When paramedics responded, they were unable to find a pulse on the resident. Paramedics attempted resuscitation for about an hour before calling the resident deceased. R1 had a "Do not resuscitate" on file but family revoked it at time of incident. Per physician report dated 09/30/2022, R1 was diagnosed with Dementia, Diabetes, and Hypertension. Staff indicate R1 was under the care of a physician and had been residing at the facility for approximately three weeks. Resident appraisal dated 09/27/2022 indicated a history of 2 open heart surgeries as well as valve replacement. Facility to obtain a copy of death certificate and forward to LPA upon receipt.