Incident investigation·September 30, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed an incident report dated 9/23/25. According to the incident report, a resident (R1) was found lying on the floor of their room on 9/21/25 covered in feces after an apparent fall. R1 told responding staff that they had gotten dizzy and fell while on their way to the restroom, according to the incident report. LPA Moleski interviewed R1, who did not remember details relating to the incident. However, R1 said that they do sometimes experience dizziness while standing. R1 also said that staff are responsive when they need assistance. LPA Moleski interviewed the medication technician who found R1 after their fall (S1) and the caregiver who assisted afterward (S2). S1 said they had gone to R1's room for a routine medication pass. S1 said that R1 told them they had been on the ground for about 10 minutes. S2 said they were alerted to R1's condition shortly after starting their shift around 7 a.m. Both S1 and S2 said they were not sure how long R1 had been on the floor, but both said the feces on R1 was not dry. S1, S2, and S3, the facility's health services director, said that R1 does not use their call button when assistance is needed. S1-S3 said that R1 did not use their call button after their fall on 9/21/25. LPA Moleski reviewed R1's file. R1's LIC 602 dated 5/5/25 indicates a diagnosis of dementia. R1's needs and services plan, dated 3/22/25, does not indicate R1 requires additional status checks beyond routine care tasks. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dial.