Incident investigation·June 23, 2021

Licensing Program Analyst (LPA) Elizabeth Hamilton, conducted an unannounced case management visit at the facility. LPA gained access to the facility, identified herself to Administrator, Carol Branshaw and explained the purpose of the visit. The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on June 14, 2021. The incident report stated that on June 10, 2021, R1 was hospitalized with an injury. On June 18, 2021, R1 passed away. On today’s date, LPA briefly toured the facility, requested copies of facility records, and interviewed staff. Facility will provide CCL the death certificate once received. No deficiencies were cited at this time. An exit interview was conducted with Administrator, Carol Branshaw to whom a copy of this report, LIC 811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt confirms receipt of these documents.