Incident investigation·April 30, 2021

Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management virtual visit, due to the COVID-19 pandemic. LPA identified herself and stated the purpose of the visit to Administrator, Wesley Lavender The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on February 4, 2021. The incident report stated that on January 29, 2021, R1 was injured by a staff member. On today’s date, LPA requested copies of facility records and interviewed the administrator. No deficiencies were cited at this time. An exit interview was conducted with Administrator, Wesley Lavender to whom a copy of this report, LIC811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.