complaint·June 25, 2025

To further investigate the allegation, Investigator Jose Santana (SI) requested additional records and conducted additional interviews. The interviews with staff revealed safety checks were conducted on residents at minimum of every two (02) hours. The review of the facility records revealed the last documented safety check completed by staff was at 2:00p.m. The interview of the staff assigned to R1 revealed they confirmed checks were completed on R1 throughout the shift and no change in condition was observed. The interview of former staff, S1, revealed they were prompted to go to R1’s room because R1 was not present for the 2:00p.m. scheduled medication distribution in the common area (living room). S1 stated they subsequently went to R1’s room to administer the missed medication, found R1 unresponsive in the bathtub and immediately called 911. The review of the EMS/911 audio records revealed at 3:21p.m., staff requested emergency medical services for R1 who was found unconscious and unresponsive, and EMS personnel determined R1 was dead on arrival due to apneic, pulseless, and without pupillary response state. The review of the death certificate revealed R1’s time of death was noted as 3:29p.m. and the cause of death was listed as acute myocardial infarction (heart attack) within minutes. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.