Incident investigation·November 13, 2025

On November 13, 2025 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a case management visit and met with Nate Echols. Today’s visit is regarding an incident report that was submitted to licensing regarding an incident that occurred on August 22, 2025. It was reported that on August 22, 2025 at approximately 8:20 PM that R1 was found on the floor by R1's door after attempting to use a folding basket for support. R1 was not using their walker or pendant. EMS was called, and R1 was transported to the hospital. On August 23, 2025, the responsible party reported that R1 required surgery. R1 has a history of falling and has a walker but forgets to use it, so staff provides cuing. R1 did not have their pendant on hand as R1 forgets to wear it. The care plan was updated to reflect additional assistance needed with transferring and cuing. LPA obtained and reviewed documentation pertaining to R1. LPA will conduct a follow-up visit if deemed necessary. No deficiencies are being cited as a result of today's visit. Exit interview was conducted. Signature on these forms acknowledges receipt of these documents.