complaint·June 19, 2023

Based on the LPA's investigation, the investigation revealed the following. Allegation – Questionable Death. Interview with S#1 -S#2, communicated that they checked on R#1 at 7:30am and 8am. S#1 went to check on R#1 at 7:30am, S#1 was talking to R#1, R#1 was only blinking at S#1, so S#1 knows R#1 was alive. S#1 left R#1 to go check on the rest of the resident’s, S#1 retuned to feed R#1 yogurt, does not recall what time it was when she returned to feed R#1. R#1 did not respond to S#1, so S#1 called administrator to advise them that R#1 was not responding. S#2 checked on R#1 around 8am, S#2 checked R#1’s blood pressure, pulse, and change R#1’s diaper and applied ointment. R#1 was still alive at that time. S#3 arrived at the facility around 9am and went to check on R#1 and R#1 was non-responsive. S#3 called hospice nurse and family to informed them that R#1 was non-responsive. Hospice nurse and family arrived around 10am. The nurse and family went to check on R#1 and family called 911. Paramedics arrived later, not sure of the exact time. The hospice nurse declared R#1 deceased. LPA reviewed the hospice records. R#1 was put into hospice on 01/19/22, R#1 was diagnosed with a terminal illness. R#1 was not expected to live more than 6 months. R#1 was on hospice for 3 days when R#1 passed away on 01/22/23, from R#1 terminal illness. There were no notes from nurse giving facility specific instructions on who should be called first, second or third in case of R#1 showing signs of distress or passing. The facility followed the procedures when residents are in hospice care. They called hospice first then the family. Interview conducted with W#1, communicated that the hospice nurse did not pronounce R#1 dead, the paramedics pronounced R#1 dead. They don’t recall there being or noticing any rigomortus. LPA reviewed the official Death Certificate, R#1 passed away of coronary artery disease and malignant Melanoma of face. Interviews conducted and records reviewed did not concur with the above allegation. 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 Honey Jean, Care giver, Care giver, and a hard copy of report was provided.