Incident investigation·December 12, 2025

Licensing Program Analysts (LPAs) Erik Zaragoza and Gabriela Castro conducted an unannounced case management visit in response to an incident report received 12/9/2025. LPAs met with Lindsey Stallings, Clinical Director, and explained the purpose of the visit. LPAs interviewed Staff #1 - 4 (S1 - S4), Resident #2 (R2), and obtained the FACE Sheet, Physician's Report, and Admissions Agreement for Resident #1 (R1). In the incident report dated 12/9/2025, it was detailed that R1's wheelchair had caught on fire after R1 placed a burning cigarette in a pouch in the back of their wheelchair, which caused R1 to sustain third degree burns on their body. S3 explained that staff was notified of R1's wheelchair becoming engulfed in flames in the front patio of the facility, and that staff had rushed over and extinguished the fire with a blanket and the trousers of the resident. R2 witnessed the incident and described that R1's wheelchair became engulfed in flames in a very short period of time, and that R1 was caught on fire for around two (2) minutes. At this time, R1 is still currently hospitalized. Following the conclusion of the visit, no deficiencies were observed. Exit interview held and a copy of the report was provided.