Incident investigation·August 8, 2024

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Rob McFarlane, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who was found with their arm wedged inside of guard rail resulting in a radial fracture. LPA interviewed staff and obtained facility records. R1 remained hospitalized at the time of the visit. No deficiencies were cited or observed on this date. An exit interview was conducted with Rob McFarlane, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.