Incident investigation·March 17, 2025

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to conduct follow up regarding an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Sheryl Johnston. On 3/14/2025, the Department received an incident report from the facility that described that on 3/5/2025, Resident 1 (R1) complained of pain during the overnight shift. [Executive Director was provided with an LIC811 Confidential Names list to identify R1] Facility staff offered R1 PRN pain medication, which R1 did not want, resulting in staff calling emergency services. R1 was transported to the hospital where R1 received medical attention and was diagnosed with multiple health conditions, including two injuries. R1 returned to the facility on 3/10/2025. During today’s visit, LPA conducted a health and safety check, observed residents in care, and reviewed and obtained copies of facility records. No deficiencies were cited on today’s date and no immediate health or safety concerns were observed. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).