Incident investigation·December 18, 2024

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met Wellness Director, Diana Rodriguez and Administrator, Rocio Granda. The facility self reported an incident that occurred on 12/10/24 involving Resident #1(R). The report indicated R1 was at dialysis center receiving treatment and began to have medical symptoms, including cardiac arrest. The dialysis center began CPR and contacted 911. R1 was transported to the hospital for evaluation and admitted to the intensive care unit. R1's Physician's Report dated 09/28/23 indicated R1 had acute respiratory failure and diabetes and required assistance with bathing, dressing/grooming, toileting and medication management. The administrator stated R1 was not admitted to the facility receiving dialysis treatment. Wellness Director explained R1 began dialysis on 11/20/24. R1 goes to dialysis center three times a week and is transported by a transportation company. On 12/10/24, the Wellness Director observed R1 as they were leaving for their dialysis appointment. R1 did not exhibit any symptoms or signs for concern. The Wellness Director also reported they touched R1's hand prior to entering the transportation vehicle, as they were assisting R1 and R1's skin was a normal temperature and not hot to the touch. There was no indication of a possible fever or other symptoms. The Wellness Director spoke with R1' social worker and discovered R1 passed away at the hospital on 12/17/24. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights.