Incident investigation·November 4, 2025

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to conduct a case management regarding an incident that occured at Jewell Home Care, the staff had noticed some facial bruising on a client on sunday 10/26/25 that exacerbated into a concerning size and shape by monday 10/27/25, which was reported by a Home Health Aid working for A Plus Prime Care Hospice, INC, a hospice agency, on the 10/28/25 tuesday. Police were called out and Adult Protective Services moved the client. Jewel Home Care is a 6 bed facility for the elderly that includes dementia support with a maxiumum of 3 residents on hospice, there are currently 1 residents with hospice, one has wound care, and 2 non ambulatory residents. LPA Wolf Petersen asked for any documentation regarding the incident in hospice care notes, The facilitiy internal care notes. Document review for the facility internal care notes is sparcely detailed, but indicates that some bruising appears to be recognized in a timing pattern that coincideds with a bathing service performed by a Home Health Aid working for PrimeCare from september on to the present. Interview with the staff does not indicate that they were trained to document changes in status(i.e. bruising), while they are up to date with mandatory training hours and topics of general rcfe care, care specific to hospice clients, and care specific to dementia clients. All staff interviewed denied interacting with the client in a way that would be consistant with the griping of the face pattern of bruising that was observed. All staff interviewed note not being concerned with the bruising until monday morning, and while concerned they decided not to contact the hospice care agency for a variety of reasons,(the hospice nurse will be coming out the next day, the hospice nurse is not willing to do anything) continued on c Page. Client was noted in hospice initial assessment to have a confused temperament and expressive of resistance to being repositioned during diaper changes. Current medication at the time of the incident back to september includes a blood thinner. Facility copies of the Hospice care notes surveyed, does not have any indication of bruising in the narrative section. Hospice care plan revised 10/14/25, indicates that training will be provided on skincare to the family/PrimaryCareGiver, administrator interview provides that the Hospice care plan did not follow through with the training noted on the hospice care plan to be provided by 10/31/25. and was not provided in that time. The LPA is providing guidance that improving note taking procedures for changes of status between shifts and coordinating note taking procedures for changes of status from visiting agency representatives would be a good idea moving forward. Timely medical intervention should occur if the concern is not related to hospice, while an expanding area of internal bleeding isn't life threatening, it would be a good idea to get a medical evaluation of some kind. No citations are issued as part of this visit, a copy of the Report was read and given to the administrator. The LPA asked for all the hospice narratives for the last 2 months. an exit interview was conducted.