Incident investigation·February 8, 2023

On 02/08/2023, Licensing Program Analysts (LPAs) L. Ibo and L. Alexander conducted an unannounced case management visit in regard to the unusual incident report received on 2/3/2023. LPAs met with Administrator, Nicolette Lake and explained the purpose of the visit. Based on unusual report received, on 2/2/2023, R1 was being fed his breakfast and was holding his mouth then he made chocking sound, his face begun to pale, and his lips was bluish he then coughed and started breathing again. Staff called 9-1-1. R1 was brought to nearby hospital. Around 2:15PM R1 was pronounced dead at the hospital. Records review and interview revealed that R1 was not under hospice care. LPAs gathered documents such as but not limited to; LIC602, pre-appraisal needs and care plan. LPAs requested from Administrator a copy of death certificate and copy of Physician orders for life-sustaining treatment (POLST). LPAs do not have available documents currently. LPAs will return to the facility as soon as all information are received. Exit interview conducted with Nicolette Lake. A copy of this report provided.