complaint·June 30, 2025

The coroner’s report indicated, Cause of death, as Positional Asphyxia with other significant conditions contributing to the death. Injury/Mode was categorized as accident. There were no other concerning or suspicious factors that contributed to R1’s death. Allegation: Staff failed to respond to R1’s call light. On December 14, 2024, R1 was found unresponsive by Staff 1 (S1) with head wedged between the mattress and the bed rail. On the day of the incident, S1 indicated she checked on R1 every two hours. At 0100 hours, S1 checked on R1 and R1 was observed to be asleep. At 0200 hours, S1 heard R1’s alarm sound and responded to R1’s room. S1 observed R1’s blankets were off and R1 was tossing and turning in bed. S1 put the blankets back on and left the room. Between 0330 and 0400 hours, R1’s alarm sounded again, and S1 responded to R1’s room within two minutes. S1 was assisting Resident 2 (R2) with a bowel movement. Once S1 responded, S1 found R1 to be unresponsive, kneeling on the floor with his head wedged between the mattress and the bedrail. There was insufficient evidence to corroborate that staff failed to respond to R1’s bed alarm in a timely manner. Allegation: Facility staff did not provide resident's records to responsible person LPA observed no formal request of resident records that are located at the facility. Administrator indicated R1’s records are provided to responsible party when requested, however, request of hospice documentation that is not located in resident's file, is directed to hospice agency. Based on the evidence, there is insufficient evidence to corroborate the three allegations listed above. Therefore, the findings are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC9099) was discussed, and a copy was provided to Assistant Administrator Elizabeth Gail.