Incident investigation·January 12, 2026

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on three (3) incidents reported to Community Care Licensing (CCL). LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Director of Resident Services Syril Jones. Note, LPA did step out for lunch from 12:25-1:25pm. Report 1: CCL received an Incident Report on 11/13/25 in which it was reported that a resident (identified as R1) had notified staff of a fall in their independent living apartment. Emergency services were contacted and R1 was assisted back into their wheelchair and was not transferred to the hospital. It was noted in the report that the day previous (11/6/25), R1 had a fall and was taken to the hospital and returned same day with several injuries. Per the report, after the second fall, R1 was advised of having a 1:1 caregiver due to the recent frequency of falls. Report 2: CCL received an Incident Report on 12/2/25 in which it was reported that a resident (identified as R2) reported pain to their side on 11/26/25. Emergency services were contacted and R2 was taken to the hospital where two (2) rib fractures were found. The report notes that R2 had a fall the day prior 11/25/25 and emergency services were called but R2 was not taken to the hospital. R2's responsible party and primary care provider were notified. Report 3: CCL received an Incident Report on 12/29/25 in which it was reported that on 12/23/25, a resident (identified as R3) was taken to the hospital by their family member due to back pain. There, it was found that R3 had compression fractures to two (2) vertebrae. Per the report, R3 returned to the facility same day. [Continued on LIC 809-C] [Continued from LIC 809] During today's visit, LPA conducted interviews and health and safety visits with R1, R2, and R3, as well as consultation with Director of Resident Services Jones. Interviews did not reveal any licensing or regulatory concerns. Regarding R1, they are currently residing in the facility's SNF (Skilled Nursing Facility) to meet higher level care needs for a health condition unrelated to this incident. Per staff interviews, R1 and their responsible party have been advised of options to meet needs as R1 is no longer suitable for independent living, whether it be transitioning to the facility's Assisted Living (AL) area or remaining in Independent Living with a private 1:1 24/7 caregiver. File review of R1's records show care meeting attempts by the facility with R1 and communications with R1's responsible party post falls. Records also revealed the facility conducted updated assessments and care plans. Records also noted R1 had begun private caregiving services 11/14/25 but discontinued them 12/8/25. R1's updated physician's report (11/21/25) note R1 to be independent in Activities of Daily Living (ADLs). Regarding R2, per interviews, it was revealed that R2 had declined transfer to the hospital by the paramedics after their initial fall, and staff promptly contacted emergency services once R2 notified them of a change in condition, thus there was no delay of medical attention by the facility. Regarding R3, per staff and resident interviews, R3 had no recent falls around the time of the incident. LPA observed no immediate health and/or safety concerns during the visit. No Deficiencies were cited during the visit as facility staff responded appropriately to each of the incidents reported. An exit interview was conducted with Executive Director Stephanie Boudreau to whom a copy of this report was provided. Their signature below confirms receipt of this document.