Incident investigation·February 19, 2026

On 2-19-2026, Licensing Program Analyst (LPA) Michael Bilger conducted a case management visit regarding a self reported incident. LPA met with Administrator Leslie Anderson and explained the purpose of the visit. LPA conducted brief interview with Administrator, staff2(S2) and resident1 (R1). LPA also reviewed incident report with Administrator. Based on incident report dated 2-17-2026, a staff member on 2-16-2026 at approximately 7:42am heard a “thump noise” and resident1 (R1) yelling. Staff member checked on R1 and observed R1 lying on right side of bedroom door. Resident was awake and alert, and complained of pain to her head and right arm. Staff initiated call to 911 timely and R1 was taken to hospital for evaluation. R1 returned back to facility same day. A scan was performed at the hospital which was noted as “clear” with no new orders. A review of incident report noted “injury cause by another resident.” Based on further review and interviews, it was determined that R1 experienced an unwitnessed fall with no evidence of another resident causing the fall or injury. As a result of this case management, no citations are issued. An exit interview was conducted and copy of this report was provided to Administrator.