Incident investigation·March 24, 2026

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to the department on 02/13/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Death report dated 02/05/2026 indicated Resident 1 (R1) had passed away at Providence Mission Hospital after a witnessed fall in the resident's room. R1 was utilizing the walker when she turned and let go in front of the care companion. R1 had 24 care companions on site. The resident was transferred to the hospital where the resident passed away diagnosed with a subdural hematoma with left pelvic fracture from a mechanical fall. Resident was on hospice care with a diagnosis of malignant neoplasm brain. Facility has been attempting to get a copy of the coroner report and will forward it to LPA upon receipt. Exit interview conducted and a copy of this report was left at the facility.