Incident investigation·January 2, 2026

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. . Upon arrival, LPA Haddadin was greeted and granted entry by Case Manager, April Pena, in which the purpose of the visit was explained. On September 29, 2025, the Department received an incident report regarding the death of Resident (R1) following an unwitnessed fall that occurred on September 26, 2025. The investigation determined as follows: R1 was admitted to the facility on January 15, 2024, to the facility Assisted Living and later transferred to the facility’s Memory Care Unit on June 06, 2025, due to increased care needs. Prior to admission, a Physician’s Report dated December 14, 2023, and a Preplacement Appraisal dated January 15, 2024, documented that R1 was ambulatory, able to communicate needs, and able to ambulate using a cane and walker. While in care, R1 experienced multiple falls over time. Per facility documentation, the first reported fall occurred on April 30, 2025, while R1 was still in assisted living. Per incident report, R1 sustained an unwitnessed fall inside their room, was able to get up without assistance, and later complained of wrist pain. R1 initially did not report the fall right away to staff. R1 was transported to the hospital following reports of pain, where they were diagnosed with a wrist fracture. After R1 transitioned to the facility Memory Care on June 06, 2025, additional falls were documented. Facility records reflected a second fall occurred on September 08, 2025; a third fall on September 16, 2025; and a fourth fall on September 26, 2025. During an interview, Staff (S1) stated that, on September 08, 2025, R1 attempted to access the dining room while doors were locked for cleaning.{***CONTINUE 809C***} S1 reported R1 was pulling on the doors while using a walker, lost balance, and fell. Hospital discharge paperwork dated September 08, 2025, documented a facial fracture involving the right maxillary sinus as a result of the fall. Regarding the September 16, 2025, fall, staff reported witnessing R1 fall in the hallway after turning into another resident, resulting in R1 losing balance and falling. R1 was transported to the hospital due to left shoulder pain, and a proximal humerus fracture was identified. On September 26, 2025, R1 experienced an unwitnessed fall in their room. Per incident report, R1 was found on the floor next to the bed. Facility staff contacted 911 and notified R1’s family. R1 reported the fall occurred while attempting to move from the bed to a table, and that the walker was located near the bed. R1 was transported to the hospital and did not return to the facility. Per interviews with staff, R1 generally used a walker but, over time, became less consistent using the walker inside the room and required redirection. Staff (S2) stated the facility had discussed R1’s increasing needs with the family and reviewed possible options, including hospice, a skilled nursing facility, or one-on-one care. S2 also stated the facility obtained a hospital bed so it could be lowered closer to the floor in an effort to reduce risk. S2 reported hospice services were scheduled to begin on October 01, 2025; however, R1 passed away prior to the start of hospice. Hospital records obtained documented that R1’s condition declined while hospitalized, including worsening breathing and decreasing oxygen levels, which led to transfer to the ICU. R1 was later pronounced deceased. A Record of Death documented the date of death as September 29, 2025, and listed cardiopulmonary arrest as the cause of death. Based on the evidence gathered through interviews and record reviews, there is insufficient evidence to support the allegation that R1’s falls were caused due to neglect. Because the preponderance of evidence has not been met, the allegation is determined to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report and confidential names list was provided to the facility's Case Manager: April Pena who signed on this report.