Incident investigation·June 16, 2025

On 06/16/2025 at 10:07AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit in regard to an incident report received. LPA met with Executive Director (ED), Scott Shahade and explained the purpose of the visit. Based on the incident report dated 06/03/2025, resident (R1) informed staff (S1) of accidentally ingesting liquid laundry soap. R1 reported that R1 mistakenly ingested liquid laundry soap that was transferred to a plastic water bottle to make it easier to use when doing R1's laundry. S2 called R1's responsible person and 911 so R1 could be evaluated by medical professionals. During visit, LPA interviewed staff and reviewed R1's file including physician's report, and incident report. R1's physician's report stated that R1 isn’t confused or disoriented. No deficiencies are being cited on this date. LPA may return on a later date. Exit interview conducted with Scott Shahade. A copy of this report provided