complaint·May 20, 2025

(Continued from LIC 9099) During the course of the investigation, the Department interviewed two of two staff members who were present at the facility on the day R1 passed away on November 26, 2024. Two of two staff reported R1 was last seen on November 25, 2024, at 8:30pm when they gave R1 medications. R1 watched television in bedroom before falling asleep. Night staff did resident rounds on November 26, 2024, at 2:30am and R1 was asleep. LPA interviewed R1’s family member, who was surprised by R1’s unexpected passing. Family member wanted to know the cause of death and questioned if there was neglect involved. R1 has been placed at this facility since facility opened on September 1, 2024. Per interview with AD, on November 26, 2024, at 6:55am staff went into room to wake R1 and discovered R1 was not breathing and unresponsive. Paramedics were immediately called and contacted the Coroner’s Office. Coroner’s Office released R1 to be picked up by the mortuary on file. At 9:30am Mortuary arrived to the facility for R1 to be cremated. The timeline of events was corroborated by the staff and the family member. LPA obtained the Natural Death Summary Report from the Coroner’s Office dated November 26, 2024. The report stated resident, “…looks clean and well cared for and there are no concerns of abuse/neglect, and no history of trauma, injuries, or substance abuse.” LPA obtained a copy of the Certified Death Certificate. The Death Certificate dated December 18, 2024, listed R1’s causes of death as: Cardiopulmonary Arrest and Atherosclerotic Heart Disease. LPA spoke with R1’s family member who felt relief that there was an official cause of death and understood R1’s health diagnoses could have contributed to R1’s unexpected death. Although the above allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the questionable death allegation is unsubstantiated. An exit interview was conducted with Miriam Esquivel, Administrator Designee and a copy of this report was provided to the facility.