Incident investigation·August 22, 2024

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report received by Community Care Licensing on 08/20/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. Death report dated 08/18/2024 indicated that on 08/13/2024, Resident 1 (R1) started coughing at lunch. Staff checked the airway and called 911. Resident was having difficulty breathing. Paramedics responded and determined there was nothing blocking the airway and requested to see the "Do not resuscitate" (DNR) paperwork. Resuscitation was not attempted due to the DNR on file. Resident passed at 12:19 PM. Per physician report dated 07/28/2024, R1 has a history of Hypertension and Hyperlipidemia. LPA toured the facility during the visit and observed the following: Facility appears clean, safe and sanitary. Residents were observed eating breakfast and relaxing in the living room. No health and safety concerns noted during the visit. Exit interview conducted and a copy of this report was left at the facility.