Complaint Investigation Report

R1 was transported to the hospital and was diagnosed with vasovagal syncope. Upon returning to the facility on the same day, R1 was placed on increased safety checks. In the evening of 7/18/2025, R1 had an unwitnessed fall in a common area and was assessed by staff for injuries and pain. R1 sustained a minor injury that required basic first aid and staff notified R1’s responsible party and physician. Approximately 5 hours later, R1 was found to be unresponsive with no pulse beside their bed. Staff started CPR, called 911, and law enforcement and paramedics responded to the facility. R1 was declared deceased by law enforcement on 7/18/2025. Review of R1’s death certificate revealed that their cause of death was congestive heart failure and Parkinson’s Disease, with onsets of years. R1’s death certificate did not include any evidence that R1’s falls in July 2025 were noted to have caused or contributed to R1’s death. Interviews with staff did not reveal any evidence that staff did not attempt to obtain or delayed appropriate medical care for R1 following their falls.

It was alleged that staff did not prevent residents from eloping from the facility, specifically Resident 2 (R2) and Resident 3 (R3) and that staff were not meeting the needs of a resident in care. Review of assessment records for R2 revealed that R2 was ambulatory and had a diagnosis of mild cognitive impairment (MCI). However, R2 was noted to not be confused or disoriented and was able to follow directions, manage their own cash resources, and leave the facility unassisted. Additionally, R2 was described as very active, healthy, and social, with no mention of any behaviors that would have required increased supervision or limits to be placed on R2’s ability to leave the facility unassisted. Review of R3’s assessment records revealed that R3 was diagnosed with MCI, was confused and disoriented, but was able to follow instructions, communicate needs, and able to leave the facility unassisted with friends and relatives. Review of the incident reports submitted to the Department by the facility between May and July 2025 did not reveal any report elopement of residents, including R2 or R3. Information collected during staff interviews did not support any evidence that residents, including R2 or R3, had eloped from the facility. Additionally, interviews with staff working at the facility in 2025 did not provide any relevant information on the supervision and care needs of R2 or R3. Interviews did not reveal any concerns that residents did not receive the care and supervision appropriate to their care levels.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. A copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the Licensee.