Complaint Investigation Report

On the allegation Questionable death the following was found:

On 03/14/2025, R1 received assistance from S1 at 0410 hours. At 0610 hours, R1 pressed their pendant. S1 responded within three minutes and eight seconds. R1 was found in their apartment after an unwitnessed fall. S1 promptly called 911. This was R1’s only fall while living at the facility. It was reported by R1 that they tripped getting out of bed to go to the bathroom and struck their head on a piece of furniture. The department received a certified copy of R1’s death certificate on 4/11/2025 that stated that R1 died on 03/15/2025 and the cause of death was listed as an intracranial hemorrhage, pathological fall, and paroxysmal atrial fibrillation. Interviews with Senior general Manager revealed that the facility advised R1s family in February 2025 that they believed R1 should be moved to memory care however this recommendation was declined. Therefore, the allegation Questionable death is Unsubstantiated.

On the allegation Staff are not meeting the needs of the residents the following was found: On 6/25/2025 R2- R4 were interviewed. R2 stated that their experience at the facility has been “wonderful.” and added that the facility staff are the “nicest” people they have ever been in contact with. R2 states that they are checked on four to five times a day and that facility staff are “in and out of the room constantly.” R2 states that if they need the facility staff’s assistance, they can pull the cord in the bathroom or press the pendant that they wear around their neck. R2 states that they once “accidentally” pressed their pendant, and the facility staff responded within “five minutes.” R3 and R4 also had similar positive experiences at the facility. LPA also observed that the facility had up to date needs and service plans for requested residents and were aware of their needs. Therefore, the allegation Staff are not meeting the needs of the residents is Unsubstantiated.