complaint·March 23, 2026

The investigation into the allegation, questionable death, revealed the following. It was alleged that Resident 1’s (R1) death was caused by the facility staff because of their lack of care and improper administration of R1’s medication. Witness 1 (W1) reported that R1 passed away 4 days after their return from the hospital and that R1 was alert and cognitive when they returned to the facility and within 24 hours was incoherent and began to decline rapidly. W1 reported that the decline led to R1’s death which was caused by facility staff. W1 did not provide any information on how staff caused the decline and death of R1. A review of records shows R1 was on hospice and passed away under the care of a Hospice Nurse (HN1). LPA attempted to contact the Hospice Nurse (HN1) but never received a response to a request for an interview. LPA attempted to contact the Hospice Doctor who signed the final hospice documents showing R1 had passed away, but no response was ever received, no interview was conducted with the Hospice Doctor. R1 moved into the facility on March 17, 2023. R1 was hospitalized on or around on April 24, 2023, and returned to the facility on April 27, 2023. R1 passed away on May 1, 2023, at 11:56 am. R1’s death certificate lists cardiopulmonary arrest as the primary cause of death and malignant neoplasm of the right lung as the secondary cause of death. Staff 1 and Staff 2 denied the allegation of not providing care to R1 and reported that unless the family was visiting, they constantly checked R1 and contacted hospice daily regarding R1. S1 and S2 reported that R1 received all their medication as prescribed and any medication administered was noted on the medication administration record (MAR). Staff 3 (S3) and Staff 4 (S4), who mainly worked in the evening, are longer employed at the facility and their contact information is no longer valid. No contact was made with S3 and S4 so they were never interviewed. Staff 5 (S5) and Staff 6 (S6) who were backup staff reported that they did not work from April 24 to April 27. S5 and S6 reported that they followed all instructions regarding the care and administration of medication for all residents and never observed any evidence that any resident was not receiving proper care. S1 and S2 reported that they followed all hospice orders and communicated with hospice regarding the care of R1 daily. A review of records shows a hospice nurse visited R1 on April 27, 2023, twice on April 28, 2023, and on May 1, 2023. R1’s MAR shows they were prescribed 7 prn medications prescribed by R1’s hospice doctor. R1’s MAR shows 1 Lorazepam 0.5 mg tablet was administered on April 30, 2023. Hyoscyamine 0.125 mg sublingual tablet was administered once on April 30, 2023, and twice on May 1, 2023. Morphine Sulfate 15 mg tablet was administered once on April 27, 2023, twice on April 28, 2023, three times on April 29, 2023, six times on April 30, 2023, and twice on May 1, 2023. Each of the medications administered can only be administered a Continued on LIC9099-C maximum of 6 times per day. The medications administered are as needed (PRN) medications and there is no mismanagement of medications indicated on the MAR. All 4 staff members interviewed denied mismanagement of medications. W1 and Witness 2 (W2) reported they did not witness anything that Staff did that would lead to R1’s death. No specific details were provided as to what facility staff did that would have led to R1’s death. Staff 1 and Staff 2 denied doing anything that would lead to R1’s death. W1, W2 and HN1 were present at the time of R1’s passing. W2 reported that S1 was present at the time of R1’s passing but S1 denied the allegation. S1 reported that they entered the room after R1’s passing. W1 and W2 reported that during their last visit on May 1, 2023, they did not witness any interactions between staff and R1. S1 reported that on May 1 around 8:30 am they noticed R1 was not responding to them, and their breathing was shallow, so they contacted hospice and R1’s responsible party. All witnesses reported different times for the arrival of HN1. It is unclear what time each witness arrived at the facility, but what is clear is that at the time of R1’s passing W1, W2 and HN1 were present and R1 passed away at 11:56am. None of the evidence gathered supports the allegation. R1 passed under the care of hospice and there is no evidence that R1’s medications were mismanaged. The investigation into the allegation, facility does not have adequate staffing to care for and supervise residents, revealed the following. Facility had 6 staff members at the time of the complaint. 2 regular staff work 5 days a week 6 am – 2 pm, 2 secondary staff work in the evening 2-10 pm, 5 days a week and 2 backup staff if the other staff are not available and they work on the days from the other staff. 2 regular staff live at the facility and are on call for the overnight hours, 10 pm to 6 am. The Administrator works 20 hours a week and is on call if necessary. The facility did not report any unusual incidents for July 2023, and only 1 report for August 2023 (R1’s death report). No unusual incident reports received for September 2023. No specific details were provided, other than 2 staff members had terminated their employment sometime in May of 2023 and this could have impacted the care and supervision provided by staff. The Administrator reported that 2 staff members did resign but they were quickly replaced and there was no interruption of staff coverage or services. LPA interviewed 3 out of 5 residents who reported no issues with care provided. 4 out of 4 staff interviewed reported there are no issues with the care provided. Witness 1 and Witness 2 reported that they have never seen any issues with the care provided and could not recall any incidents where Continued on LIC9099-C residents were not provided with care and supervision. LPA attempted to contact the party responsible for 5 residents but never received any response so no interviews were conducted. No evidence was gathered to support the allegation. Based on the evidence gathered the allegations are deemed Unsubstantiated. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with the Administrator, and a copy of the report was provided. The investigation into the allegation, staff did not provide resident’s authorized representative a refund, revealed the following. Resident 1 (R1) moved into the facility on March 17, 2023, and passed away on May 1, 2023. R1’s responsible party and Administrator both reported that R1 passed away on May 1, 2023, and a refund for May 2023 was requested on May 2, 2023. The Administrator reported that the refund check was mailed to R1’s responsible party and the check was cashed but R1’s responsible party reported they never received the check. A review of facility records shows that the Administrator received a letter from Bank of America reporting that the refund check for R1’s responsible party was fraudulently cashed, and the facility’s account was credited on August 17, 2023. The Administrator reported that a new refund check was sent to R1’s responsible party on August 18, 2023. R1’s responsible party reported that they received the refund check in September 2023, but they do not remember the exact day. The Administrator reported that the delay was due to the first refund check being fraudulently cashed and waiting for the bank to complete their investigation. R1’s responsible party reported they told the Administrator they never received the refund check and then didn’t hear anything until August 2023 when they received the refund check. R1’s responsible party reported that after they received the refund check it was deposited into their account with no issues. Based on the evidence gathered the allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator, and a copy of the report was provided.