Incident investigation·April 16, 2026

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report received by the department on 04/10/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Death report dated 04/09/2026 indicated care staff had conducted a safety check on Resident 1 (R1) and the resident was observed unresponsive. CPR was initiated by staff while waiting for paramedics to respond. Once paramedics responded, the resident was pronounced deceased at 4:47 AM. Facility noted case #1132 and 26-011632. Per facility notes, R1 was last checked by staff at 2:00 AM. Per physician report dated 02/03/2026, R1 is diagnosed with Parkinson's Disease. Per incident reports submitted to the department, R1 was observed with a loss of consciousness on 04/06/2026 but refused transport to hospital. On 04/07/2026, R1 was transported to hospital for dizziness. Facility indicated resident had an un-witnessed fall but R1 denied hitting their head. R1 left the hospital "Against medical advice" and was returned to the facility by a friend. The resident was referred for hospice care on 04/08/2026 but passed before admitted to hospice care. LPA toured the facility during the visit and observed the following: Facility is a three story building and appears clean, safe and sanitary. LPA observed residents dining in the dining room and walking about the facility. Residents appeared clean and well taken care of. LPA observed ample emergency food and water. LPA observed no health or safety concerns during the visit. Facility to forward death certificate once receipt. Exit interview conducted and a copy of this report was left at the facility.