Incident investigation·April 11, 2025

On 04/11/2025, Licensing Program Analyst (LPA) Sarah Benson arrived at the facility to conduct an unannounced case management visit in response to an incident report submitted to licensing on 4-4-25 and explained the purpose of the visit. LPA Benson met with Lori Whitburn Clinical Services Director Kristi Bracisco Resident Care Coordinator. LPA Benson reviewed the resident file, medications records and documentation from hospital pertaining to R1’s incident. LPA interviewed staff and the resident. LPA determined that facility took appropriate action in responding to incident on 4-3-25. No deficiencies cited. Exit interview done and copy of report left with the facility. Exit interview conducted.