Facility Evaluation Report

04/14/2025 12:30 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Gail Mason. Today’s visit is regarding incident reports that were received concerning Client 1 (C1).

It was reported that on 03/26/2026 Client 1 (C1) fell at home, obtained a scratch on their head, first aid was provided. Licensee states client’s psych doctor has been making medication changes which are causing client to be unsteady. 03/26/2026 Client fell at day program, fell backward and struck the back of their head on a table resulting in a laceration. 911 was called, C1 was transported to hospital, treated and discharged on the same day. On 03/29/2026 C1 was at home, unsteady on their feet. C1 fell in their room and fell in common area. C1 was transported to ER for evaluation, was in the hospital for two nights. On 03/31/2026 C1 was release from hospital.

During the course of the investigation, it was learned that the administrator started working with C1's physician in 2025 when C1 first started exhibiting the new symptoms. and experiencing falls. There have been no additional falls since the fall on 03/29/2026. Administrator is currently working with C1's physician to determine which medications need to be discontinued or added. C1's physician had ordered additional lab work, physical therapy, occupational therapy for C1. During the visit LPA observed C1 to be stable on their feet but somewhat unsettled.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to administrator Gail Mason.