Incident investigation·April 9, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Annaliese Anderson, care staff, who contacted the Co-Administrator, by phone. LPA spoke to the Co-Administrator and was advised she was attending an appointment and was unavailable for a couple of hours. LPA observed resident (R1) seated at the dining room table using their cell phone. (3) residents returned to the facility from day program at the end of the inspection . LPA discussed the recent fall with caregiver, who was at the facility, but did not see the fall. Staff explained (R1) fell around 7:00 pm last night, and sustained a small abrasion on the left side of the forehead. Staff called the Emergency Medical Technicians (EMT's) who arrived and assessed (R1), who declined to go out for further medical treatment. Staff stated she observed (R1) every (30) minutes and noted they were confused about the time until they went to sleep. Staff stated (R1) got up two times during the night, which is normal, and was back to normal this morning. A Home Health nurse and assistant assessed (R1) this morning around 10:00-11:00 am and instructed staff to apply an ice pack and administer Tylenol, as needed. (R1) stated to LPA they fell last night while walking into their room with a cup of water, denied being in pain, and appeared to be coherent. LPA observed (R1) to have a slight bruise on their forehead, to be using a cane, which was provided to them about (2) weeks ago from the Physical Therapist, and was told (R1) previously used a walker in February 2026. LPA reviewed (R1)'s resident file, including physician's report, which notes (R1) is ambulatory and independent with all ADL's. (R1) will continued to be monitored by staff, the Co-Administrator and Home Health, and staff and will contact 9-1-1 if there is a medical emergency. It appears the facility took appropriate steps following the unwitnessed fall. LPA toured the interior of the facility and did not observe any health and safety risks or personal rights violations. There are no deficiencies issued in this report. Exit interview. Copy of report provided.