Follow-up·January 9, 2024

On 1/9/24 at 11:00am Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management inspection to ensure the health and safety of residents and address additional questions regarding the death of R1. LPA met with Assistant Administrator Susan McClure and explained the purpose of today’s visit. The death report indicated that, on 1/4/2024, resident (R1) was discovered behind the facility building hanging from a tree at approximately 3:50pm. A camera footage revealed that R1 secured a rope over a tree branch, climbed up on his walker and then pushed it way and hung himself. LPA Truong conducted file review for former resident and conducted interviews with staff members to get additional information regarding the former resident and to obtain additional information leading up to his death and the actions of the facility immediately after resident was found unresponsive. LPA could not interview staff who first discovered R1 as she is not present at the time of inspection. Based on the interviews, information gathered, and documentation reviewed there were no deficiencies assessed at the time of inspection. Exit interview was conducted and a copy of this report was left at the facility.