complaint·August 29, 2025

caused or contributed to R1’s death. Interview with facility administrator confirms that R1 had a fall, resulting in subdural hematoma on or around August 27, 2024. The administrator also confirms that R1 was found unresponsive on or around September 5, 2024, and passed away on September 9, 2024. The administrator denies that R1’s fall, leading to the subdural hematoma, contributed to R1’s death. The administrator stated R1’s current diagnoses and condition contributed to the cause of death. Review of R1’s records indicate that R1 was already taking medications to prevent heart attack and stroke. R1’s physical health status when admitted on January 27, 2023, was marked fair by the physician. Per death certificate, cause of death was stroke and hypertension. On April 21, 2025, LPA Cava requested for a Program Clinical Consultant (PCC) review to confirm if the subdural hematoma, contributed to R1’s death. On August 11, 2025, PCC completed their review. The following was revealed and PCC concludes: · R1 already had some chronic conditions with a history of stroke at admission to the facility. · Given R1’s medical history, R1 had multiple coexisting conditions that made R1 prone to bleeding and increased risk for stroke. · “According to CDC, previous stroke or transient ischemic attack increases the chances of having another stroke.” · During a follow up appointment on September 4, 2024, there was no concern about further bleeding or any signs of stroke. Based on this information obtained and a review conducted by PCC, there is insufficient evidence to prove that R1’s fall, which resulted in subdural hematoma, contributed to R1’s death. Therefore, the allegation of Questionable Death, is deemed Unsubstantiated at this time. Staff did not respond to resident’s requests for assistance in a timely manner: In regards to the allegation, it was reported that R1 was instructed to yell out for staff when requesting for assistance, instead of using the call button provided. Interview with the administrator deny the allegation. Administrator stated R1 and all facility residents are provided a portable push button device to carry with them to activate when assistance needed. On August 27, 2024, R1 had a fall, that caused damage to the portable push button device. Because of the damage to the device, R1 had to yell out for help. Staff did come to assist R1. Paramedics were called and R1 was taken to the hospital. LPA was unable to interview Staff 1 (S1), as S1 no longer works at the facility. Interview with three (3) of three residents could not corroborate with the allegation of having to yell for staff assistance. LPA conducted a physical plant inspection, and observed a push button device, provided to each resident in care. A test of this device proves to be functional. According to the three residents that were interviewed, there were no issues when utilizing this device. Based on the information obtained, the allegation of staff not responding to resident requests for assistance in a timely manner could not be proven. Therefore, the allegation is deemed Unsubstantiated at this time.