Incident investigation·October 2, 2023

On 10/2/23, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning incident report received. LPA met with Administrator Mary Linde. LPA explained the purpose of today's visit. On 8/14/23 Licensing received a report regarding a resident (R1) that had suicidal ideation. An SOC 341 was also filed. Based on records reviews, R1 was in close monitoring. R1 was assigned a private aide that constantly checks on him/her and is outside the room with the door ajar. R1 has no diagnosis of dementia and family is aware that his/her medications are being managed by the facility. On 8/12/23, a family member picked up medication for R1. Family member went to facility and directly gave the medication to the resident without facility knowledge. The exchange happened with the private aide not being aware due to R1 leaving after lunch. A nurse checked on the room and no medication was found. Around dinner time, R1 was found in room unrousable. 911 was called and R1 was sent to hospital. On the same day, another round of search was done in the room and an empty bottle of pills was found hidden at the bottom of the open trash bag. R1 died at the hospital on 8/15/23. No deficiencies are cited during the visit. Report is reviewed with the administrator and a copy is provided.