complaint·November 9, 2023

It was determined that staff were aware that R1 was under hospice care and had shown a decline in condition which was conductive to R1’s death. Staff do not have concerns regarding staff that are providing care to the residents at the facility. Documents reviewed revealed the following: Facility submitted a Death Report dated 6/16/23 to the department and notes that on 6/9/23 R1 passed away at 11:25pm of coronary artery disease (CAD). Death Certificate dated 7/3/23 notes health conditions as the cause of death. Facility’s Letter Head notes R1 entered hospice on 2/11/23. Per documents reviewed R1 was actively receiving hospice services. R1’s Physician’s Report dated 2/11/23 notes, “no treatment needed for CAD as R1 is on hospice”. Outside Provider Notes - noted by hospice Skilled Nurse dated 5/31/23, 6/2/23, 6/7/23, and 6/9/23 note R1’s change in condition and show R1’s health declining. Deaths occurred at the facility between 4/26/23 to 7/1/23 were notified to the department via death reports. 6 out of the 8 deaths were of residents under hospice care due to a terminal illness or heart disease. The other 2 deaths recorder residents had a sudden change in condition and were send out to the hospital upon observing the change in condition. Per death reports both residents passed away at the hospital. Although R1 seem to have been well before 10:00pm, the hospice documents reviewed show that R1 was declining, R1's death was determined to be due to health conditions and not to other reasons. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Sherry Fischer and a copy of this report was provided.