Incident investigation·March 24, 2026

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management visit. The LPA introduced herself and disclosed the purpose of the visit to Executive Director Wes Hebner, later Memory Care Director River Jon Pagala joined the visit. Today's visit was in response to an Incident Report (Dated 3/19/2026) submitted to the Department for Resident 1 (R1). Per facility reporting, R1 sustained a fall on 3/13/2026, which resulted in a clavicle fracture. Reports indicate R1 was taken to the hospital and returned to the facility the same day. LPA conducted a review of R1's pertinent records and interviewed staff. LPA conducted a health and safety check for R1. No health and safety concerns were identified and no deficiencies were cited during today's visit. An exit interview was conducted with Memory Care Director Pagala, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.