Incident investigation·November 25, 2025

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced case management visit at the facility to follow up on an incident report received by the Department on 11/14/2025. For this visit, LPA Rodriguez met with Nurse Managers- Melissa Goldman and Sheila Weathers. Per incident report, resident 1 (R1) sustained a fall at the facility in room, on 11/10/2025, due to getting foot caught in foot rest of wheelchair, to which resulted to R1 sustaining an ankle fracture. Per documentation review of R1's files, R1 has been referred to as a fall risk since being diagnosed with a stroke and left-sided weakness as of this year. LPA observed that R1 is currently recovering at the facility and is doing well. R1 has a 24-hour caregiver and is obtaining services from hospice. Per documentation review, interviews and observations, R1's fracture was due to an accidental fall, and not due to staff neglect. For this visit, no health and safety concerns were observed. No citations issued. An exit interview was conducted with Nurse Managers Goldman and Weathers. A copy of this report was explained and provided.