Incident investigation·September 23, 2025

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to follow up on a self-death report dated 7/21/25. LPA met with Administrative Assistant, Lisa DiBartolo. Per death report, on 7/19/25 at 12:37pm, resident (R1) was in the dining room having lunch and showed signs of chocking, staff called 911 immediately, who performed required treatment, but they were unsuccessful and R1 was declared deceased at 12:43pm. Responsible parties were notified. Upon the department was notified, LPA requested death certificate for review due to R1 was not receiving hospice services and pending investigation status was observed in the certificate. On 9/16/25, Licensee submitted death certificate dated 9/11/25 indicating that R1 chocked on a piece of hamburger, which resulted in them passing away while under the care of the facility. During today's visit, LPA reviewed R1's physician report dated 5/20/25 and care plan dated 5/13/25 including any doctor's order involving special diet, food restrictions or assistance needed regarding feeding the resident, which were not instructed by the doctor as needed. R1 was needing constant supervision due to disruptive behavior towards others, which it was related to their diagnosis. Also, LPA confirmed that the call alert system was working properly, and LIC500 Personnel Report indicates that there was staff present during the incident who got alerted, and timely contacted the medical emergency responders to assist resident in the facility. LPA conducted interviews with staff (S1 and S2) who confirmed above information. Based on records review and interviews conducted with staff it appears like the facility followed up adequate protocol including timely medical assistance for resident. No deficiencies cited during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.