Incident investigation·October 14, 2025

Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday October 14, 2025, to conduct a case management on an incident report received by the Department on Monday October 13, 2025. LPA met with Sabrina Boyle and Shalon Morris, Resident Services Director. LPA learned that on 10/11/2025, R1 pressed their wall cord around 4:10am. Staff arrived and found R1 on the floor. R1 stated they fell. R1 was independent of ADLS except for medication management. LPA obtained a copy of R1's assessment, care plan and physicians report. R1 was recently reassessed on 9/16/2025. R1 is currently at the hospital and will then be transferred to a SNF for rehab. Shalon will reassess R1 before they return to the facility. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.