Incident investigation·September 23, 2025

On 9/23/2025 at 3:00PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards to three incident reports received between 8/23/2025- 9/9/2025. LPA met with Executive Director, Jennifer Coons and explained the reason for the visit. It was reported that on 8/23/2025 R1 had a fall that resulted in a right hip fracture. On 8/24/2025 R2 had a fall that resulted in a right hip fracture. On 9/9/2025 R3 had a fall that resulted in a right hip fracture. R1 and R3 are both memory care residents. LPA reviewed the footage of R1's fall and saw that it was not at fault of anyone and that staff responded to the fall within seven minutes. R1 was transferred to the hospital by paramedics and responsible parties notified. LPA interviewed Director of Resident Care Services (DRCS) in regards to R2 and R3 falls and found that staff located R2 when staff came to assist them with their morning ADL's. R2 did not activate their pendent however. R2 was also sent out to the hospital and responsible parties notified. DRCS states that on the night of the fall when R3 came out of their apartment to see what the noise was they fell. Staff located R3 quickly after the fall because they were next door assisting another resident when it happened which is what initially woke R3 up. R3 was transferred to the hospital by paramedics and responsible parties notified. R1 has since returned to the facility with an updated care plan. R2 and R3 have not yet returned but will be reassessed before returning. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.