complaint·January 23, 2025

A review of hospice records revealed Resident #2 (R2) was receiving hospice services for a terminal illness and last visit by hospice agency professional was 08/30/2024. Death Report states that on 09/02/2024 resident was found unresponsive at 4:15p.m., emergency arrived at 4:30p.m., paramedics pronounced resident dead at 5:16p.m. and coroners picked up resident at 10:20p.m. Visitor’s Log does not show R2 had a visitor on 09/02/2024. A review of staff schedule for 09/02/2024 shows facility had three (03) caregivers and one (01) MedTech for both morning and afternoon shifts. A review of Physician’s Report and Needs and Services Plan does not indicate R2 had swallowing difficulties. During interviews with staff, all staff stated resident was found unresponsive by MedTech Staff #1 (S1) as they were making medication rounds. S1 checked vitals, requested emergency services, and attempted to resuscitate R2. Staff #2 (S2) added paramedics and police arrived, then shortly after, the coroners. During interviews with residents, Resident #1 (R1) stated they did not witness anything, does not know the name of the alleged neglected resident, and only heard from others what happened. Resident #3 (R3) stated they did not find their roommate R2 choking or try to assist R2 while choking. R3 stated they found R2 deceased and that it looked like R2 was sleeping. R3 called out for help and staff came within thirty (30) minutes, however, R3 also stated R2’s doctor was in the room before staff arrived but did not attempt to resuscitate. R3 contrarily added that it was the doctor who called out for help. All other residents stated they are unaware of anyone choking to death or staff failing to aid anyone choking. Based on record reviews and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.