complaint·March 12, 2025

Staff was interviewed at approximately 4pm and facility records were reviewed. Additional attempts were made to reach the reporting party on 05/10/2024; 08/15/2024; 11/19/2024; and on 01/14/2025 but was unsuccessful. A subsequent visit was conducted on 02/19/2025, and interviews were conducted with six (6) staff from approximately 11:30am-3:00pm; additional records pertaining to former resident (R1) were requested and reviewed; interview conducted with potential witnesses. Following is a summary of the allegations and investigation finding: Regarding Allegation: Facility failed to seek timely medical attention for resident resulting in a questionable death. Information was provided that resident #1 (R1) was observed showing signs of a stroke on 01/09/2024 and facility did not seek timely medical attention for R1; resident passed away within 48 hours. No additional information was provided about the resident’s questionable death identifiers. Several attempts were made to reach the reporting party to obtain additional information however no response was received. To investigate the allegation, the LPA reviewed the Department’s database for Death Reports (LIC624 A). The LIC 624A report received in our office on 01/12/2024, indicate the manner of death to be of natural causes due to conditions contributing to death. Facility staff interviewed reported that R1 was not observed showing any signs of a stroke prior to death. R1 was admitted to Affinity Healthcare Resources on 12/30/2023. The hospice notes reflect that due to R1’s poor prognosis and declining condition, family wished to decrease hospitalization and treatment and opted for hospice care for palliative measures and symptom management. R1 was seen by the hospice nurse for routine skilled nursing and support services. Resident was placed on comfort care level of care for respiratory distress and pain; discharge summary obtained from Affinity Healthcare Resource noted resident #1’s terminal diagnosis of Athscl Heart disease of native coronary artery. On 01/11/2024, resident expired peacefully with hospice nurse and family at bedside; immediate cause of death documented as “cardiopulmonary arrest”. Based on the information obtained through record review and interviews; the allegations “Facility failed to seek timely medical attention for resident resulting in a questionable death”, is deemed Unsubstantiated at this time. (Continue to LIC9099c) Regarding allegations: 1) Staff inappropriately handled the residents resulting in bruising; 2) Staff did not provide a resident care service as agreed; 3) Residents sustained pressure injuries due to neglect; 4) Resident fell due to staff neglect; 5) Staff did not respond to a resident's calls for assistance; 6) Staff violated residents’ personal rights; 7) Facility retained a resident requiring a higher level of care. Reporting party was contacted several times to gather supporting information for these allegations and no response was received; no resident names or dates of alleged incidents was provided. To investigate these allegations LPA conducted interview with facility ED and staff; toured the memory care unit and assisted living side. Residents of the “Neighborhood” were unable to be interviewed due to lack of capacity. Random interviews were conducted with residents residing in the assisted living side and other potential witnesses; no mistreatment or neglect was reported. LPA also reviewed facility incident and death reports from 11/2023 – 1/2024; no discrepancies found. ED and Director of Resident Care Services stated that facility did not retain any resident requiring higher level of care; no resident retained with pressure injury greater than stage 2. Based on the information obtained through facility record review and interviews conducted allegations listed above are deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided.