Incident investigation·January 6, 2026

Purpose of Visit: Incident Follow-Up – Death of Resident Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing.  LPA met with the Executive Director and the Director of Resident Care and discussed the purpose of the visit. This report documents the follow-up related to the death of Resident 1 (R1). A review of records indicates that R1 was assessed on 03/26/2025 and determined to be independent and not requiring assistance. A Physician’s Report dated 04/25/2025 documented that R1 was 89 years old with a diagnosis of Atrial Fibrillation (A-Fib). The report noted no physical or mental health limitations, no diagnosis of dementia, and that R1 was able to communicate needs, follow instructions, self-administer medications, ambulate independently, and transfer independently. R1 was able to leave the community unassisted and was in good physical health. Continued on 809C Facility notes dated 12/11/2025 reflect that R1 remained independent with ambulation, was physically in good condition, worked with a personal trainer once per week, required no redirection, and was actively engaged in community social activities. On 12/26/2025, records indicate that R1 experienced a fall in their apartment and struck the back of their head. No bleeding was noted. R1 was taking Xarelto, a blood thinner. Emergency services were contacted, and R1 was transported to the hospital via 911 for further evaluation. R1 was evaluated and returned to the facility the same day. Staff conducted rounds to make sure R1 was doing well. On 12/30/2025, R1 was found unresponsive in bed by their partner, who contacted the front desk. The nurse on duty assessed R1 and noted no pulse, no heart sounds, and no respirations. R1 was designated as Full Code, and CPR was initiated but was unsuccessful. Emergency Medical Services responded and pronounced R1 deceased on 12/30/2025 at 7:42 a.m. No additional information was obtained during this follow-up. Based on the information gathered, the facility appears to have acted appropriately and in compliance with applicable regulations regarding this incident. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Director of Resident Care along with appeal rights (LIC9058 03/22) and an LIC 811.