Incident investigation·October 23, 2025

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to initiate a case management visit. LPA Rodgers identified herself and was granted entry by Executive Director Natalie Carlborg and stated the purpose of the visit. The incident involved Resident #1 (R1) (see LIC 811 – Confidential Names List), who experienced an unwitnessed fall in R1’s room on October 18, 2025. R1 reported to staff that they may have fallen and complained of pain. Staff contacted emergency services, and R1 was transported to the emergency department, where they were diagnosed with a broken femur. R1 subsequently underwent surgery on October 19, 2025. R1’s responsible party and primary care physician were notified of the injury and the transport to the emergency department, in accordance with reporting requirements. Later in the day on October 18, 2025, staff were escorting Resident #2 (R2) to their room when R2 reported that they had been in an altercation with R1. Later that evening, R2 also reported conflicting details regarding the altercation; however, some of these claims were determined to be not plausible given R2’s condition and circumstances. Record review reveals that R2 had a recent medical diagnosis involving an infection. The Department reviewed the physician reports for both R1 and R2, which confirmed that both residents have a diagnosis of dementia. During today’s visit, Licensing Program Analyst (LPA) Rodgers interviewed staff, toured the facility, and requested and obtained documents relevant to the incident. LPA informed (ED) Carlborg that additional follow-up via telephone or in-person visits may be necessary. No deficiency were noted or cited during the visit. An exit interview was conducted with ED Carlborg. A copy of this report, the LIC 811, and the Licensee Appeal Rights (LIC 9058) were provided at the conclusion of the visit. The signature below confirms receipt of these documents..