Incident investigation·April 21, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Executive Director (ED) Sarah Stel. The purpose of the visit was to follow-up on an incident and death report received for resident (R1) who resided in the independent living section. On 04/19/2023, R1 passed away by possible carbon monoxide poisoning. R1 was found by a family member who called 911. Upon arrival of the paramedics, R1 was pronounced deceased. During visit, LPA was accompanied by ED and another staff to observe the exterior part of the cottage where R1 passed away. LPA interviewed 2 staff members (S1 - S2). LPA obtained documents to include the resident roster, staff roster, R1's face sheet (admission record), reported incident, and physician's report. Based on record review, R1 was diagnosed with a chronic degenerative disease. This case management - incident visit will be pending investigation. This report was reviewed with Executive Director (ED) Sarah Stel and a copy of the report was provided.