Complaint Investigation Report

On 05/19/2025, LPA Urena interviewed the resident’s (R1) family members and the Reporting Party (RP) from approximately 9:00 a.m. to 10:19 a.m. LPA Urena reviewed the following records for R1: Death Certificate, Physician’s Report (LIC 602A), Appraisal/Needs and Service Plan (LIC 628), Centrally Stored Medication and Destruction Record (LIC 622), Medication Administration Record (MAR), Weekly Nursing Assessment Forms, Monthly Doctor’s Office Visits, and Providence Holy Cross Medical Center medical records.

On 06/05/2025, Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegation listed above. The LPA met with the Administrator Mark Samuel and explained the reason for the visit. The LPA Urena interviewed the Administrator and facility staff from approximately 12:21 p.m. to 2:30 p.m. and requested additional documents pertinent to the investigation.

On 04/03/2026, Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegation listed above. The LPA met with the Administrator Mark Samuel and explained the reason for the visit. LPA Urena interviewed staff at approximately 11:10 a.m. and requested additional documents pertinent to the investigation.

On the allegation that R1’s death was due to negligence from facility staff; it is the concern of the reporting party (RP) that when R1 arrived at the hospital on 01/29/2025, “R1 was in bad shape”. R1 had bruising all over the right side of their face and right eye. The RP was informed that R1 was already unconscious when R1 arrived at the hospital and had not woken up. Furthermore, the RP reported that when R1 arrived at the hospital, R1’s blood sugar was very low and possibly the reason for R1’s fall and facial bruise, leading to hospitalization. R1 passed away at the hospital on 02/08/2025. RP believes that the fall incident and death were due to negligence of the facility, because facility staff was not supervising R1 closely enough. Furthermore, the RP reported that R1 had falls in the past, however the RP was unable to provide dates for the falls. The last time the RP visited R1 was around the beginning of December 2024 (prior to the incident when R1 fell and was taken to the hospital 01/29/2025). Family members expressed concern about R1’s cause of death to hospital staff; however, hospital staff informed family that the hospital would not conduct an autopsy and family members were given a telephone number to call for the autopsy to be done. An autopsy was not conducted due to the family’s personal reasons.