Incident investigation·May 20, 2026

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Regional Health and Wellness Director Janet Mangaya to discuss the purpose of the visit. During the visit Health and Wellness Director Raquel Mathews arrived to the facility. Today's visit is in response to the self reported fall of Resident 1 (R1 - see LIC811 Confidential Names List).  R1 suffered a fall resulting in a hip fracture on 05/10/2026. Staff interviews revealed that the fall occurred In R1's room with a family member, outside of caregiver assistance. A written statement from the family member and facility care notes showed that the fall occurred while R1 was being assisted with toileting with their family member. The required stability equipment was in place during the time of the fall. The information showed that upon standing, R1 stepped back without enough support and fell to the ground, causing a hip fracture. LPA conducted a wellness check at the facility; R1 was not present due being admitted into a rehabilitation facility. No health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Health and Wellness Director Raquel Mathews who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.