Incident investigation·January 16, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to conduct a case management visit to follow-up on a visit from 11/02/2023. The visit was regarding an incident that occurred at the facility on 10/12/2023 pertaining to resident (R1). LPA met with Administrator, Nicholas Inneh. On 10/26/2023, LPA Dolores visited the facility unannounced and was made aware of a resident (R1) who passed away. Based on investigation, it was found that on 10/12/2023, staff noticed R1 was choking on food during dinner time. Staff immediately called 911 and began CPR and First Aid (Heimlich Maneuvers) until the paramedics arrived. R1 was transported to the hospital and pronounced deceased on 10/13/2023. Based on record review, R1’s cause of death was due to lack of oxygen to the brain from choking on food. It was also noted that R1 had a throat condition. Based on staff interview, for dinner that night R1 was served a chicken burrito that was cut into three pieces by the staff. R1 was provided a regular diet. It was stated by staff that R1 has had a history of choking on food. Prior to R1’s passing, staff did observe something in R1’s throat. The observation was stated to be brought to the attention of the Administrator. The staff also informed R1’s doctor, however, R1’s doctor did not provide a change of order to R1’s diet. Based on review of records, there is no documentation of the staff’s observation regarding R1’s throat condition. There is also no documentation that R1 was seen by the doctor in the year 2023 regarding R1’s throat condition. SEE LIC809-C. The review of R1’s records showed that R1 was at the hospital in October 2020, and it was noted R1 was diagnosed with a throat condition. In the discharge summary, it was noted there was an order for small portions. Based on interview, it was stated that during that time, R1 was being fed a regular diet. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in the death of a resident in care. An additional Civil Penalty for a violation resulting in the death of a resident is pending review. A plan of correction was developed with the Administrator, Nicholas Inneh. A copy of the report and appeal rights were also provided to the Administrator, Nicholas Inneh.