Incident investigation·October 23, 2025

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced case management visit at facility to follow up on an incident report the department received on 10/8/2025. For this visit, LPA Rodriguez met with facility administrator (AD) Ashley Croslin. Per incident report, resident 1 (R1) sustained a fall at the facility on 10/3/2025, which resulted into R1 sustaining a fracture on the knee. Per incident report, it stated that R1 fell due to R1 reporting that the texture of the floor was uneven. During this visit, LPA observed that the floor where R1 tripped, was a flat wooden surface, and was free of any hazards and obstructions. LPA observed video footage of the incident and observed that R1 was walking on a flat surface floor, and was on the way to the health and wellness office, however while walking, R1 accidentally tripped on their own feet, which resulted to R1 sustaining a injury. LPA met with R1 who is recovering, getting physical therapy and was observed to be doing well. For this visit, no health and safety concerns were oberved. No citations. An exit interview was conducted with AD Croslin. A copy of this report was provided and explained.