Incident investigation·February 11, 2026

02/11/2026 Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Allezmoy Bourque, Director of Health Services. The purpose of the visit was to follow up on a special incident report (SIR) that was self-submitted to Community Care Licensing (CCL). CCL received an SIR on 01/26/2026. Report stated that on 01/26/2026, during routine rounds, a staff member (S1) assisted resident (R1) with a transfer from R1s wheelchair to the toilet. During the transfer, the wheelchair moved out from under R1, and S1 was unable to maintain support long enough for R1 to be seated on the toilet. S1 safely assisted R1 to the floor and radioed for additional assistance. Upon arrival of additional staff, R1 was found of the floor, semi-wedged between the right side of the toilet and the wall. R1 was assessed and asked if they were experiencing pain to which R1 reported discomfort to their right shoulder. Staff attempted to assist R1 up on two occasions without any success. R1 requested that 911 be called for assistance. LPA obtained additional documentation and was informed R1 is receiving physical therapy. No Deficiencies Cited during visit. Exit interview conducted with Director of Health Services. Copy of report was provided along with LIC811 (Confidential Names).