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Where was care provided?

State

Facility or agency name (optional)

What type of care setting?

Nursing facility / skilled nursingAssisted living or residential careHome care (in the resident's home)Not sure

Is there a current safety concern?

Yes — someone may be in immediate dangerI have an ongoing concern, but no immediate dangerNo current safety concern (resident has moved or passed away)

Your relationship to the resident

Have you already spoken with a lawyer about this?

NoYes, I've spoken with a lawyerYes, a lawyer currently represents us

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