Complaint Investigation Report

**** This report supersedes the original complaint investigation report dated 12/19/2025 to update facility information. Investigation findings remain the same. ****

This investigation was completed by Investigator Bendana with the Investigations Branch and revealed the following:

Allegation: Questionable death. It is alleged that staff neglected R1 contributing to R1’s unnatural death. The investigation conducted by the Investigations branch revealed that it did not provide sufficient evidence to substantiate questionable death against Administrator. Interviews conducted, police reports, EMS report indicate R1 died of natural causes. S1 saw R1 alive at approximately 0530 hours, during a round check. R1 did not complain of pain and showed no indications of suffering or distress. The death certificate listed the cause of death as cardiopulmonary arrest and hypertension. There was no autopsy performed or requested. The police incident report stated that the death was of natural causes and that there were no signs of trauma. When EMS arrived, R1 was in rigor mortis. R1's pupils were fixed and dilated, and there was no pulse or neurological response. P1 reported R1 was an elderly person who was very ill. The night before their passing, R1's blood sugar level was 172. Based on the totality of circumstances, there is not enough evidence to indicate staff neglected R1 or their neglect contributed to R1’s unnatural death; therefore, the allegation is unsubstantiated.

Based on statements and interviews conducted by the Investigations Branch as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Due to the closure of the facility on 12/01/2025 initiated by the Licensee, a copy of this report along with the Appeals Rights will be emailed to the former Licensee's information on file.