LPA conducted three (3) in person interviews with facility staff, one (1) in person interview with a hospice agency nurse, a file and record review, along with obtained copies of pertinent documents relevant to the investigation.

During today's visit starting at 9:40 a.m. LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and the facility is in compliance with title 22 regulations.

Records review included, but was not limited to, documentation from Hospice #1 (H1), Hospice #2 (H2), hospital and medical records, facility records, paramedic reports, and R1’s death certificate. H2 documentation indicated hospice care began on 08/19/2022. R1’s primary diagnoses at admission were sequelae following unspecified cerebrovascular disease and dementia. R1 had a history of hip replacement, was non-ambulatory, and had recently sustained a fall with negative X-ray results. R1 qualified for hospice due to increased daytime sleeping, unexplained weight loss, and low blood pressure. Additional notes throughout 2023 documented increased confusion, Sundowner’s symptoms, decreased food intake, a UTI, muscle wasting, lethargy, and progressive memory loss.

H1 records showed R1 was admitted on 10/02/2025 after discharge from H2 on 10/01/2025 due to stabilization and prolonged prognosis. R1 was in a recertification period from 10/02/2025 to 11/30/2025, with an estimated life expectancy of six months or less. On 10/03/2025, the facility reported that R1 sustained a witnessed fall. No injuries were initially noted; however, R1 later exhibited increased weakness, decreased mobility, and right upper leg pain and contacted hospice. Report continued on LIC 9099C PAGE 3....

An X-ray on 10/04/2025 returned negative for fractures. Continued pain prompted another X-ray on 10/10/2025, which on 10/11/2025 confirmed a right distal femur fracture. The family was notified and revoked hospice services at that time.

Hospital records documented R1’s admission to the Emergency Room on 10/11/2025 at approximately 12:57 p.m. R1 was diagnosed with a right distal femur fracture and treated with a hinged knee brace. R1 also presented with severe protein-calorie malnutrition, dementia, and pain associated with cognitive impairment. Radiology confirmed limited orthopedic intervention options, and on 10/12/2025, the treating physician recommended non-operative management due to surgical risk. R1 remained hospitalized until 10/14/2025, when they were discharged back to hospice care at the facility under H1.

R1 passed away on the morning of 10/15/2025. The death certificate lists the cause of death as cardiopulmonary arrest and cerebrovascular disease, classified as natural causes.

Staff interview with S1 confirmed that R1 had been on hospice for nearly four years—three years under H2 before discharge due to improved condition, followed by reassessment and admission to H1. S1 stated they were working at the time of the incident but were not the staff member assisting R1 when the fall occurred.

According to S1, on 10/03/2025 at approximately 1:30 p.m., R1 requested to use the restroom after lunch and was assisted by S2. While in the restroom, S2 called S1 for assistance after R1 experienced a sudden dizzy spell and fell forward onto their knees, scraping their forehead. Upon responding, S1 found R1 on their knees, helped lift R1, transferred them to bed at R1’s request. Staff #2 (S2) tended to the scrape on R1’s forehead.

S1 notified the Administrator and hospice nurse promptly and monitored R1 until hospice staff arrived. FM1 arrived around 3:00 p.m. and was informed of the incident. S1 reported that once the hospice nurse assumed care, they were no longer involved in R1’s treatment following the fall.

Interview with S2 revealed that on 10/03/2025 at approximately 1:30 p.m., R1 requested to use the restroom and was assisted by S2. S2 lifted R1 from their wheelchair and seated them on the toilet. After moving the wheelchair into the hallway, R1 appeared to experience a sudden dizzy spell and fell forward off the toilet, landing on their knees and scraping their forehead after striking the door.

Report continued on LIC 9099C PAGE 4....

S2 attempted to prevent the fall but was unable to do so. S2 immediately called S1 for assistance. S2 provided first aid as S1 notified hospice and the Administrator. FM1 arrived during first aid and was informed of the fall. The hospice nurse arrived shortly thereafter, assessed R1, determined emergency services were not required, ordered a hip X-ray, and administered pain medication. S2 assisted with R1’s care for the remainder of the shift.

S2 stated that when they returned for their next shift on 10/10/2025, R1 was in bed resting. During FM1’s visit that day, FM1 reported R1 was experiencing knee pain and requested an additional X-ray. S2 relayed this information to the hospice nurse, who ordered a knee X-ray. S2 later learned that R1 had sustained a fracture and had been transported to the hospital. S2 stated that 10/10/2025 was the last day they provided care to R1 and confirmed they had received training in lifting techniques.

Interview with the hospice nurse (HCN), employed by H2, revealed that R1 was elderly, weak, medically unstable, and already experiencing a decline in health prior to the fall. R1 required total assistance with activities of daily living, which was provided by facility caregivers. HCN routinely assessed R1’s vitals, mobility, pain, psychosocial status, and monitored caregiver reports for any changes in condition.

HCN stated they were notified of the fall around 2:00 p.m. on 10/03/2025 and responded shortly thereafter. Upon arrival, HCN assessed R1, bandaged a minor scrape to the forehead, and ordered an X-ray of R1’s right leg due to a complaint of pain. The X-ray returned negative for fracture. HCN administered comfort care, including pain medication, and determined emergency services were not required. HCN explained that under H1 policy, hospice nurses do not contact 911; emergency services must be initiated by the caregiver or family.

In the days following the fall, HCN continued comfort care measures. On 10/11/2025, FM1 requested a second X-ray due to R1’s continued complaints of right knee pain. The X-ray revealed a fracture, and FM1 immediately contacted 911. HCN stated that once emergency services are contacted, hospice services are automatically revoked. To HCN’s knowledge, R1 was transported to the hospital and remained there for three days.

Report continued on LIC 9099C PAGE 5....

R1 was discharged on 10/14/2025 and re-admitted to H1 for hospice services with orders for comfort care and pain management. HCN continued monitoring R1 until R1’s passing on the morning of 10/15/2025.

Interview with the facility Administrator (AD) revealed that R1 moved into the facility in 2021. R1 required full assistance with ADLs and was non-ambulatory, using a wheelchair for mobility. FM1 was very involved in R1’s care and visited daily, often staying four hours. At admission, R1 had diagnoses of dementia and cerebrovascular disease, and was identified as a high fall risk. Due to occasional attempts to get out of bed related to dementia, bed rails were installed for safety.

On 10/03/2025, AD was not at the facility. Around 3:00 p.m., AD received a call from S1 informing them of R1’s fall and that HCN was in route. AD was later notified that an X-ray had been ordered for R1’s hip and that first aid was provided for a minor head scrape. AD arrived at the facility later that evening and observed R1 to be stable and not reporting pain. AD interviewed S1 and S2. S2 reported that around 1:30 p.m., they assisted R1 to the restroom, lifted R1 to the toilet, and positioned the wheelchair just outside the restroom. While standing near R1, R1 suddenly lost balance and fell forward. S2 attempted to prevent the fall but both lost balance, causing R1 to strike their knee and scrape their head. S2 called out to S1, who assisted in lifting R1 back into the wheelchair. S2 treated the scrape, while S1 contacted HCN and AD. S2 then transported R1 to their room to await HCN’s arrival. FM1 arrived before HCN and was informed of the incident.

Interview with FM1 revealed they were satisfied with the care R1 received and visited daily from approximately 3:00 p.m. to 8:00 p.m. FM1 was familiar with the caregivers, the Administrator, and hospice staff. FM1 stated R1 had incontinence issues and wore diapers but preferred that R1 be toileted for bowel movements due to constipation. FM1 reported they had given permission for staff to strap R1 to the toilet because R1 was a fall risk, though FM1 was unsure if this was implemented.

FM1 stated R1 had been under hospice care with H2 for approximately three years before being discharged on 10/01/2025 due to stabilized condition and extended prognosis. FM1 disagreed with the discharge and requested reassessment. H1 began evaluating R1 on 10/02/2025.

Report continued on LIC 9099C PAGE 6....

Regarding the incident on 10/03/2025, FM1 reported they were not notified until their daily visit around 3:00 p.m. When they arrived, R1 had a bandage on their head, their legs elevated, and appeared distressed, complaining of right leg pain. S2 informed FM1 that R1 had fallen forward off the toilet, striking their head and knee. FM1 requested an X-ray of R1’s right hip and femur due to R1’s history of hip replacement. FM1 recalled HCN arriving later that afternoon, re-bandaging the minor head scrape, determining emergency services were not required, and placing an X-ray order around 6:00 p.m. Results showed no fracture.

FM1 stated that R1 did not complain of pain the following day due to morphine prescribed for comfort care. Later in the week, R1 began expressing leg pain again. FM1 reported this to HCN, who ordered an additional X-ray of R1’s right knee. On 10/11/2025, results confirmed a fracture. FM1 requested R1 be transported to the hospital via ambulance. FM1 stated the physician advised that comfort care not surgery was the most appropriate course of treatment given R1’s condition, and FM1 agreed. R1 was treated with a brace and remained hospitalized until 10/14/2025. R1 was discharged back to the facility under 24-hour hospice care with H1 and passed away on the morning of 10/15/2025.

On the allegation, Questionable Death it is the concern of the Reporting Party (RP) that the facility staff neglected R1 leading to their death. To investigate this complaint, the Department conducted in person interviews, telephonic interviews, file and record review, reviewed hospital records, hospice records and obtained copies of pertinent documentation relevant to the investigation.

Based on the records review, including but not limited to documentation from H1 and H2 hospice agencies, hospital and medical records, facility records, paramedic reports, staff interviews, and R1’s death certificate, it was determined that R1’s death was the result of Cerebral Vascular Disease and Cardiopulmonary Arrest, with no additional contributing factors. It was also determined the staff sufficiently supervised R1 during toileting and was not negligent in R1’s care.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Questionable Death is deemed unsubstantiated at this time.

Report continued on LIC 9099C PAGE 7....

On the allegation, Due to neglect, resident sustained serious injury while in care it is the concern of the Reporting Party (RP) that the facility staff dropped R1 leading to a fracture. To investigate this complaint, the Department conducted in person interviews, telephonic interviews, file and record review, reviewed hospital records, hospice records and obtained copies of pertinent documentation relevant to the investigation.

Interviews and documentation confirmed that on 10/03/2025, R1 experienced a sudden dizzy spell while being toileted by S2. S2 attempted to prevent the fall but was unable to do so. Staff responded immediately, provided first aid, notified the Administrator and hospice nurse, and continued monitoring R1. The hospice nurse assessed R1 shortly afterward, treated a minor scrape, and ordered diagnostic imaging, which initially showed no injury. Staff continued to follow hospice guidance and monitored R1 throughout the week. When pain persisted, additional imaging was ordered, which identified a fracture several days later. Staff then contacted hospice and medical personnel, and R1 was transferred for further evaluation.

Evidence shows staff responded promptly, followed required reporting protocols, provided necessary care and supervision, and collaborated with hospice staff. There is no evidence indicating neglect, improper supervision, or failure to provide care.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Due to neglect, resident sustained serious injury while in care is deemed unsubstantiated at this time.

On the allegation, Staff did not seek timely medical care for resident it is the concern of the Reporting Party (RP) that the facility staff did not call 911 during R1 incident and instead called the hospice nurse. To investigate this complaint, the Department conducted in person interviews, telephonic interviews, file and record review, reviewed hospital records, hospice records and obtained copies of pertinent documentation relevant to the investigation.

Documentation and interviews confirmed that on 10/03/2025, R1 experienced a sudden dizzy spell and fell while being toileted by S2. Staff responded immediately, assisted R1, provided first aid, notified the Administrator, and contacted the hospice nurse (HCN). HCN arrived shortly thereafter, assessed R1, treated a minor scrape, and ordered an X-ray based on R1’s reported pain. The X-ray was completed and returned negative for fracture. HCN determined emergency services were not required at that time and directed staff to continue comfort care and monitoring. Report continued on LIC 9099C PAGE 8....

Evidence demonstrates that staff communicated changes in R1’s condition to hospice appropriately, followed direction from licensed hospice clinicians, and sought medical evaluation in accordance with hospice care protocols. There is no evidence indicating that staff delayed seeking medical attention or failed to follow required procedures.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not seek timely medical care for resident is deemed unsubstantiated at this time.

On the allegation, Staff did not report residents fall to residents responsible party or appropriate agencies timely it is the concern of the Reporting Party (RP) that the facility staff did not inform R1’s family of the incident in a timely manner. To investigate this complaint, the Department conducted in person interviews, telephonic interviews, file and record review, reviewed hospital records, hospice records and obtained copies of pertinent documentation relevant to the investigation.

Interviews and documentation confirmed that on 10/03/2025 at approximately 1:30 p.m., R1 experienced a sudden dizzy spell and fell while being assisted to the restroom. S2 immediately called S1 for assistance, provided first aid, and notified the Administrator and hospice nurse (HCN). HCN arrived shortly thereafter and conducted an assessment.

Interview with FM1 revealed that they arrived at the facility at approximately 3:00 p.m., their usual daily visit time, and were informed of the fall at that time. FM1 confirmed staff notified them of the incident upon arrival and provided details regarding the fall and R1’s condition. Interviews with S1, S2, and the Administrator were consistent in stating that FM1 was informed during their regular visit time the same afternoon.

Evidence reviewed shows staff followed required reporting practices by notifying the Administrator, hospice nurse, and responsible party promptly after the fall. There was no evidence supporting delays or failures in reporting. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not report residents fall to resident’s responsible party or appropriate agencies timely is deemed unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was provided.