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25 | Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit based on an incident report and death report received for resident (R1). LPA met with Executive Director (ED), Jett Cabuena.
On 04/05/2023, the Department received an incident report and death report for resident (R1). On 03/29/2023, R1 was eating breakfast in the dining room when it was observed R1 was choking on food. Staff immediately administered the Heimlich Maneuver and called 911. EMS arrived on scene between 5-10 minutes from the initial call. EMS arrived and took over care for the resident. R1 expired at the facility.
During visit, LPA interviewed the ED. Based on interview, ED confirmed the details of the report and stated R1 was given eggs, potatoes and sausages for breakfast. ED stated R1 does not have history of choking on food. LPA obtained records to include R1's physician's report, needs and services plan, hospice records, POLST, DNR, special diet board of memory care residents, and staff (S1) first aid certification. Based on record review, R1 was given a regular diet. R1 was able to feed self with no assistance required. R1's medical records did not indicate R1 required a special diet (ex: pureed or mechanical soft foods).
The facility is pending the coroner's report. The facility will forward the Department R1's coroner's report and death certificate once obtained.
No deficiencies are cited per California Code of Regulations, Title 22.
This report was reviewed with Executive Director, Jett Cabuena and a copy of the report was provided. |