Incident investigation·June 25, 2025

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to follow up on a death report received by the department on 06/20/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Death report dated 06/18/2025 indicated that while Resident 1 (R1) was taking evening medications, the resident started to shake and became unresponsive. 911 was called and staff started CPR. Once the paramedics responded, resident death was called. Resident was a "Do not resuscitate." Resident had been hospitalized from 05/31-06/03/2025 for Acute Metabolic Encephalopathy. While hospitalized, R1's family had consulted regarding hospice care but requested to put off admission until a family trip was concluded. Per physician report dated 12/24/2024, R1 is diagnosed with Osteoporosis, Hypertension, Hypothyroidism and Osteoarthritis. Facility to forward a copy of the death certificate to LPA once obtained. Exit interview conducted and a copy of this report was left at the facility.