Complaint Investigation Report

The facility staff checked on R1 seven hours later and noted R1 to be in good spirits and tolerating well. The Department was unable to conduct an interview with R1 for this complaint due to R1 passing away on July 18, 2026. The Department conducted four staff interviews. The four staff interviewed confirmed that R1 sustained a fall while at the facility on June 22, 2026. However, the staff reported that R1 did not sustain any obvious injuries as a result of the fall and that R1 did not complain of any pain. Therefore, immediate medical attention was not required for R1. The staff interviewed reported that R1 was continuously checked on to determine if R1 needed any further treatment after the fact.

Regarding the allegation, staff did not reassess resident for changes in his health condition, the following has been concluded: It was alleged that staff did not reassess R1 for changes in his health condition. The Department reviewed the facility's progress notes for R1 between the dates of May 8, through July 2, 2026. Per the facility's progress notes, on June 23, 2026, R1 complained of soreness, body aches, and a cough. Staff then notified R1's Responsible Party who stated that they would have R1's Nurse Practitioner check him out. Approximately seven hours later, R1 again complained of generalized body aches and a cough. Staff also noted R1 with a decreased appetite during dinner. On the following day, June 24, 2026, staff noted R1 to be dry heaving. Staff asked R1 if he wanted to be sent out to the hospital but R1 refused. A visitor for R1 then called 9-1-1 due to their concerns about R1's condition. However, R1 refused the paramedics once they arrived to assess him. On June 25, 2026, staff noted R1 to not be eating well and that R1 vomited a dark output during lunch. 9-1-1 was then called for R1 who agreed to be transferred to the hospital. The Department was unable to conduct an interview with R1 for this complaint due to R1 passing away on July 18, 2026. The Department conducted four staff interviews. One staff was unable to provide any information into this allegation. However, the three other staff denied the allegation. The staff reported that 9-1-1 was offered to R1 when he first displayed his symptoms, however, R1 declined to be assessed by the paramedics.

Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the two allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director John Goodwin and Health and Wellness Director Putri Tarigan. A copy of the report was provided at time of visit.