Incident investigation·March 20, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 03/11/2025. The report pertains to the death of Resident #1 (R1). It was reported R1 was sent to the hospital on February 23th due to a fall and passed away on March 8th at the hospital. During today's visit, the LPA conducted an interview with the Executive Director, Health Service Director, one (1) resident, conducted a brief tour of the facility and obtained copies of pertinent documents. Further investigation is required prior to issuing findings. Exit interview conducted. A copy of the report was issued to the Executive Director.