Incident investigation·June 4, 2025

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Case Management regarding 3 incidents that occurred on 5/30/25 and 5/31/25. LPA requested copies of Hospice notes for R1 regarding R1's fall. Facility does not have any notes from Hospice regarding the visit for R1's fall. Administrator requested copies from Hospice. LPA observed R1 to have a lot of swelling above and below the left eye. Administrator advised the swelling was noticed this morning and hospice was notified and it was unrelated to R1's fall. LPA requested copy of Hospice Care plan. LPA was advised it is unknown if R2 actually fell. R2 reported to facility staff she fell and called 911. LPA requested copies of discharge paperwork for R2. Administrator advised R3 did not hit her head. LPA followed up on the incident with R3. Administrator advised R3 did not his his head. LPA will review paperwork and will return at a later date if deficiencies are warranted. A copy of this report was provided to Administrator.