Incident investigation·December 11, 2025

On 12/11/2025, Licensing Program Analyst (LPA) Valerie Flores made an unannounced visit to the facility for the purpose of conducting a case management - incident visit. LPA met with Executive Director, Austin Irwin, whom was informed the purpose of the visit. During the visit, LPA collected pertinent documentation and conducted interviews with relevant parties. On 12/11/2025 at approximately 10:30AM, LPA received a call from Executive Director Austin Irwin informing LPA of a possible suicide. Upon arrival, information received reported that Home Health nurse was conducting a routine visit with Resident #1 (R1). Home Health nurse entered into R1's bedroom and did not observe R1 to be present inside the bedroom. Home Health nurse further observed R1's oxygen cord lying on the floor. Home Health nurse followed the cord which lead out to R1's second floor balcony and observed R1, who was lying on the flowerbed at ground level. Home Health nurse immediately called emergency services and notified Executive Director. It was reported that Home Health Nurse, Executive Director, and Resident Service Director ran out to assess R1. R1 was observed to be unresponsive and without a pulse. R1 resided in a shared unit but had their own bedroom. R1 was residing at the facility for approximately two months. During the time of stay, staff did not observe any changes of behaviors. R1's physician report conducted on 10/3/2025 divulged that R1 did not have suicidal ideations and did not require constant supervision. Resident #2 (R2), who shares a common wall with R1, reports that R1 and R2 went down to eat breakfast together that morning. Upon returning to their shared unit, R2 reports that they did not hear nor observe anything out of the ordinary. At this time, the death determination is still pending autopsy. LPA requested a copy of the death certificate once it has been available to the facility. During today's visit, LPA did not observe any health and safety concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Austin Irwin.