Incident investigation·July 11, 2025

At 1:30 p.m. on 07/11/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management visit came about after the facility submitted two (02) reports detailing resident falls in which staff may have not responded in a timely manner. The first incident happened on 06/30/25. Resident #1 (R1) fell near their bathroom around 5:00 a.m. R1 yelled for help. Resident #2 (R2) overheard R1 yelling for help around 5:00 a.m. The report noted that R1 did not use the call system and refused medical treatment when staff came to assist R1 around 7:15 a.m. The administrator was interviewed at 1:40 p.m. today and noted that they were nearby at the time of the fall and did not hear R1 yelling for help. The second incident happened on 07/04/25. Around 4:00 a.m., Resident #3 (R3) fell and waited two (02) hours for staff assistance. The administrator stated that the two (02) staff on shift at the time were interviewed and claimed that they responded to assist R3 quickly, but they did not reset the timer on the call system, so it showed that the response did take approximately two (02) hours. Due to the need for more information, LPA will continue the investigation at a future date to determine if residents were assisted in a timely manner after falling. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.