Complaint Investigation Report

***********************************************This is an Amended Report*************************************************

Complaint alleged that the facility failed to seek timely medical attention for R1. Based on interviews, staff found R1 outside of the facility and carried R1 inside. Based on interviews conducted, the Department determined that facility staff were aware that R1 was not breathing when found outside and waited to perform CPR until 911 was called which was approximately 40 minutes after R1 was found unresponsive and not breathing as staff were attempting to locate R1’s Do Not Resuscitate(DNR) order which R1 did not have.

The Allegations above are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegations are valid because the preponderance of evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

An immediate $500 civil penalty was assessed due to the deficiencies resulting in the death of a resident.

Additional Civil Penalties may be assessed at a later date.

This report was reviewed with the Administrator and a copy of the report along with Appeal Rights was left at the facility. Report sent via email to Administrator on 6/24/2025.