Incident investigation·March 29, 2022

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with staff, Janine Sorensen. Licensee, Ami Kumar was not able to come to the facility, but she was available by phone and gave authorization to staff to sign the report. LPA conducted risk assessment with Staff at the facility entrance. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet. LPA is following up on a self-incident report received at CCL on 3/28/22 regarding R1's death. Per Incident Report on 3/26/22 staff went to check on resident (R1) to reposition as usual and R1 began to foam at the mouth, their breathing started to change, 911 was contacted immediately and while on the phone then R1 stopped breathing, fire department arrived at the facility they were provided with R1's DNR dated 11/27/17 on file and R1 was declared death at 8:55pm. Responsible parties were notified, police department was also contacted due that resident was not in hospice and they filed a report #22-3419 and coroner's case number is 1-22-0227. During today's visit LPA was informed by Licensee that R1 celebrated their birthday a couples days before their death and resident was a normal behavior and routine after their birthday. LPA also reviewed R1's Physician's report, needs and services plan. Licensee agreed to submit police report and death certification to CCL as soon as they receive it. No deficiencies cited during today's visit.