Incident investigation·August 23, 2023

08/23/2023 11:20 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Sue Todd and Wellness Director Nicole Braswell. The purpose of this visit was to conduct a case management investigation. Today's meeting concerns an investigation into a non-hospice death report that was received from the facility on 08/18/2023 regarding an incident that occurred at the facility on 08/17/2023. It was reported that on 08/17/2023 staff found Resident 1 (R1) unresponsive when checking on R1 after assisting R1 to bed. Once staff found R1 unresponsive EMS, local police, and administrator were called . R1 had been observed to be at baseline mentation and condition at breakfast, lunch, and dinner and had attended activities the same day. Administrator stated R1 has lived in the facility’s memory care since 2016 R1 was in gradual decline but was still ambulatory, still fed themselves but was starting to need more help. R1 still participated in activities. R1 had a particularly good day, was tired before dinner, sat in the living room after dinner for a while after dinner. Staff said he was not in distress or pain, he just put his head on the pillow and passed away. No deficiencies are being cited as a result of today’s visit.