complaint·April 17, 2025

Allegation: Questionable Death. T h e complaint alleges that on August 17, 2024 97 year old Memory Care resident (R1) woke up between the hours of 5AM- 6AM and informed staff they were having trouble breathing and needed to go to the hospital. According to information obtained, staff called paramedics, but the resident died outside the facility while being transferred on the gurney. It is alleged R1 was healthy; therefore, R1's cause of death i.e., COVID-19 is questionable. A total of three (3) staff were interviewed, of which all denied the allegation. Staff stated that a staff member heard the resident coughing and immediately contacted R1's physician. The resident was taken to their doctor, and developed COVID-19 a week later; August 15, 2024. Staff reported that the night before the resident passed away, they did not feel well but did not have a fever. According to staff interviews, on 8/17/2024 at approximately 6:10 AM, a staff person checked on the resident and found the resident with a black substance around the mouth, left shoulder, and bed pad. According to staff, R1 was alert and oriented and expressed they wanted to be taken to the hospital. Staff observed labored breathing and called 911 emergency. Staff stated paramedics were provided the POLST form, and shortly after exiting the facility R1 went into cardiac arrest. The resident died inside the ambulance. Based on record review, the findings indicate resident (R1) had pre-existing health conditions. Authorized representative was interviewed and no facility negligence was reported. LPA obtained a copy of the Death Certificate that stated the immediate cause of death was COVID-19. There is insufficient evidence to corroborate the allegation. Allegation: Licensee is not ensuring that resident's records are provided to resident's responsible party as necessary. According to information obtained, authorized representative and family member asked facility staff for health records, and were told that the documents would be provided. It is alleged that after several failed requests, family sent a certified letter to the facility on 11/22/2024, but never received any of the documents requested. Staff stated that facility always provides records to responsible parties. However, in this case, the family member requesting the documents was not R1's authorized representative/responsible party. Based on record review, an Advance Health Care Directive was in place, only naming the authorized representative and not the other family member. Authorized representative stated they never requested documents, and the other family member does not have Power of Attorney for health or finances. Therefore, there is no evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to Executive Director Kimberly Sanchez.