Complaint·June 5, 2025

Investigation revealed the following Allegation #1: Questionable death The complaint alleges that R1 passed away due to the facility staff's failure to provide lifesaving oxygen. The department interviewed with A1, who stated that R1 required assistance with medication management and oxygen device maintenance. A1 stated R1 was independent in all other areas of daily living. The department interviewed with S2. S2 stated at 9:30 am, on January 31, 2024, S2 administered R1’s medication and ensured R1’s oxygen cannula was properly placed. At 11:30 AM, staff (S2) returned to R1’s room, inspected R1’s oxygen equipment, and utilized R1's pulse oximeter to measure R1’s oxygen saturation levels and oxygen levels were at 93-95%. S2 observed that R1's oxygen cannula was not properly positioned, and S2 repositioned R1’s nasal cannula. R1 was sleeping when S2 repositioned R1’s nasal cannula. R1 woke while receiving assistance from S2 and asked S2 to leave, so that R1 could go back to sleep. S2 stated during the 11:30 am visit with R1, S2 did not observe any signs of a respiratory deficiency, nor did R1 report having difficulties breathing. At approximately 12:30 pm, S2 conducted a status check on R1. S2 found R1 was lying in bed and napping. During this status check, W1 was present and asked S2 to return at 1:30 pm, as R1 would be awake. W1 reported no issues to S2 during this status check. At approximately 1:30 pm, S2 returned to R1's room and found R1 still sleeping. W1 informed S2 that R1 requested not to be disturbed. At approximately 3:00 pm, W1 approached S2 to report that R1 was experiencing shortness of breath. S2 called 911 while returning to R1’s room. S2 observed that R1 was “gurgling”. S2 checked R1’s airway and was instructed by 911 to begin CPR. At approximately 3:15 pm, EMS arrived and continued care. At 3:57 PM, R1 was pronounced deceased. The cause of death was determined to be cardiac arrest due to hypoxia, severe gastroparesis, and diabetes mellitus type II. Evaluation Report Continues LIC9099-C Based on the evidence gathered, interviews, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. As a result, the allegation is Unsubstantiated. Allegation #2: Facility staff did not meet the resident’s oxygen needs. It is alleged that the facility staff failed to meet the Resident's (R1) oxygen needs and this resulted in R1’s oxygen saturation level to drop below sixty (60). On April 10,2024, the department interviewed S2, who stated that on January 31, 2024, at 9:30 AM, S2 checked on Resident R1 to administer medications and ensure R1's oxygen cannula was properly placed. At approximately 11:30 am, S2 returned to R1’s room and checked R1’s oxygen levels, which were between 93% and 95%. S2 observed that R1's oxygen cannula was not positioned correctly and S2 provided assistance by repositioning R1’s oxygen cannula. S2 stated there were no signs of respiratory distress, and R1 did not report any difficulties in breathing. At approximately 12:30 pm, S2 conducted a status check on R1 and found R1 lying in bed and napping. W1 was present during the check and reported no issues to S2. At approximately 1:30 pm, S2 returned to R1's room and saw that R1 was still sleeping. W1 informed S2 that R1 had requested not to be disturbed. At approximately 3:00 PM, W1 approached S2 to report that R1's mouth was open and that R1 was gasping for air. S2 called 911, and the operator instructed S2 begin CPR. According to departmental records, Emergency Medical Services (EMS) arrived at 3:15 PM, and CPR continued during their arrival. EMS administered (3) doses of epinephrine; however, R1 did not respond to treatment and was pronounced deceased at 3:57 PM. Evaluation Report Continues LIC9099-C On February 27, 2024, the department interviewed four staff members, S1, S2, S3, and S4, all of whom denied the allegation. The department also interviewed two residents, R2 and R3, who both expressed that they enjoy living there and feel well cared for by the staff. Based on the evidence gathered, interviews, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. As a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the report was provided to the Senior Executive Director Stephanie Koffman.