Follow-up·February 6, 2024

On 2/6/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver. Administrator was notified and arrived to assist. On 2/5/24, the department received a death report and phone contact from the administrator regarding the unexpected death of a resident. On 2/2/24 at approximately 6:30 AM, R1 had an unwitnessed fall from their wheelchair. Caregiver responded when they heard the fall. R1 was unresponsive. Caregiver initiated CPR and activated 9-1-1. R1 was unable to be revived. Records review showed R1 to have extensive chronic health issues. R1 had limited verbal communication ability yet was constantly observed and no health concerns were apparent in the previous 24 hours. LPA observed the location of the fall outside the bathroom and found no hazards. As a result of today’s inspection, no deficiencies were noted. LPA did advise that the door lock be removed from the fire door to resident rooms. Licensee will consider installing a fire door release magnet system. Report reviewed. Copy of report and appeal rights provided