Incident investigation·September 11, 2025

09/11/2025 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director April Kale. Today’s visit is regarding an incident report that was received by licensing on 07/28/2025 regarding an incident that occurred on 07/21/2025. It was reported that on 07/21/2025 at 03:10 AM a med tech observed Resident 1 (R1) on the floor in their room directly in front of their bed. R1 complained of pain to their shoulder and leg. EMS was called to evaluate R1 and transported R1 to hospital. R1 was diagnosed with fracture to the proximal femur bone and admitted to hospital with a plan to undergo rehabilitation at a skilled nursing facility. During the investigation it was learned that R1 had been on frequent checks due to being a fall risk and had been observed by staff at approximately 01:10 AM. Staff complete rounds at a minimum of every two hours. EMS was called at 03:15 AM and arrived at the facility at 03:20 AM. R1 has returned back to the facility. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director April Kale.