Incident investigation·March 12, 2026

03/12/2026 10:45 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident report that was submitted to licensing on 01/19/2026. On 01/17/2026 10:50 PM Resident 1 (R1) was found on the floor in the hallway in front of their bathroom. R1 staled that they were experiencing pain In !heir left shoulder hip and knee. EMS was called and transported R1 to the local hospital for further evaluation. R1 was diagnosed with fracture of libial osteophyte. R1 was advised to wear an immobilizer at all times except when bathing. No weight bearing on right leg until orthopedist was seen, follow up with orthopedic clinic. During the investigation it was learned that R1 was not always complaint with wearing the prescribed brace. In order to prevent this from occurring again the facility has updated the care plan for R1 to include standby assisting for dressing, toileting and other ADLs to include more hands-on assistance for bathing. R1 was advised by physical therapy and their physician to use a wheelchair with staff following and a four-wheel walker with standby assistance. 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 Irene Davis.