Incident investigation·January 22, 2025

On 1/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with Administrator . On 11/6/24, the department received a Death Notification for R1's passing on 11/4/24 while hospitalized. The notification stated that R1 was sent to the hospital on 11/1/24, approximately 9 AM, for a "declining baseline". R1's death was not expected and R1 was not on hospice care. On 11/14/24, the Department conducted an initial case management visit regarding the death of R1. LPA requested and reviewed R1 records prior to the 11/14/24 visit. LPA received additional records on 11/14/24 as well conducting interviews of resident care director, memory care director and three caregivers. The department also received and reviewed medical records and the death certificate for R1. At this time, the department finds that resident exhibited changes of condition and had not taken several prescribed medications for three days prior to R1’s 11/1/24 hospitalization. The changes and missed medication were not reported to R1’s physician and assistance was not provided to R1 for medical care. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided.