Incident investigation·March 12, 2026

Licensing Program Analyst (LPA) Hannah Rodgers conducted an announced case management visit to follow up on an incident observed during a complaint visit that is unrelated to the complaint allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Assistant Administrator Mary Gonzalez. During the unrelated complaint visit, LPA observed a resident with a fracture boot on their right ankle. On October 20, 2025, the Department received an incident report that described that on October 16, 2025, R1 requested to be sent out to the hospital and was diagnosed with a right leg fracture. During today’s visit, LPA briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents. There were no deficiencies cited during today's visit. However, this incident may require further follow-up visits. An exit interview was conducted with Assistant Administrator Mary Gonzalez, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to.