Complaint Investigation Report

The investigation revealed the following:

Regarding allegation of questionable death, it was alleged that a staff member (S-1) provided drugs to Resident #1 (R-1) which resulted in resident passing.

Interviews with staff indicated that R-1 was self responsible, did not need assistance with activities of daily living, and often left the facility during the daytime. R-1 was able to leave the facility unassisted as noted in the physician’s report. Staff did not witness any staff giving R-1 drugs, however, one staff found substances once in R-1’s room. Staff questioned R-1 about the drug and how it was obtained but the resident did not state who provided it. Although staff could not confirm R-1 used drugs, they did observe R-1 returning to the facility intoxicated, more often prior to the death. They attempted to intervene by offering services to R-1, however, R-1 would become agitated and aggressive whenever staff reached out. R-1 passed away on 1/17/23. According to the coroner’s medical report, the immediate cause of death was due to arteriosclerotic cardiovascular disease and was determined as a natural cause. Based on the information gathered, the allegation of a questionable death for Resident #1 (R-1) was unsubstantiated.

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.

An exit interview was conducted with Ms. Sanchez. A copy of this report along with the appeal rights were provided.