Incident investigation·May 7, 2025

Licensing Program Analyst (LPA) conducted an unannounced case management - incident visit and met with Executive Director (ED) Meghian Geul. On 4/2/20254, the Department received an incident report from the facility that an incident occurred on 4/29/2025 at the facility. On 4/29/2025 around 2:00PM, resident R1 was walking in the memory care unit living room by resident R2's chair, R2 pushed resident R1 without reason. R1 fell on the ground. STaff called 911 and R1 was sent to hospital. LPA interviewed ED, 2 residents (R1, R2) and 2 witness staff (S1, S2). LPA requested physician reports and service plans of resident R1 and R2. This case needs further investigation. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.