Incident investigation·May 13, 2026

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 13, 2026 to conduct a case management visit on an incident which was reported to the Department on March 30, 2026. LPA met with Resident Services Director Shalon and explained the purpose of the visit. LPA and Shalon discussed R1's fall which occurred on 3/26/2026. R1 was found on the floor by NOC shift staff. R1 denied falling or hitting their head. The following day, R1 spoke with Shalon and stated that they did fall but did not tell staff. R1 was experiencing pain in their left hip and could not stand. AMR was called for R1. R1 was diagnosed with a left hip fracture. LPA reviewed' R1's physicians report and care plan. R1 was independent in ambulation, toileting, dressing, and grooming. Facility staff were conducting status checks 4x per shift and assisting with medication management. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.