Incident investigation·August 13, 2024

Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident. LPA reviewed special incident report dated 8/12/2024 stating R1 choked on food from lunch. R1 did not recover from the incident. R1 passed away. R1 physician's report dated 6/12/2023 and 7/31/2024 confirmed that there were no food restrictions or special diets. The facility was provided with a police report number and was also given a Corner's report number with a badge number. The department has copies of both. During today's visit, LPA reviewed and obtained copies of R1's file, medical records related to the incident, service plan, and the food menu for the day. No citation issued today. Exit interview was conducted.