complaint·April 17, 2026

Findings indicated that R1 experienced respiratory complications. A CT scan revealed no abnormalities to the carotid arteries; however, documentation noted a blockage of the internal carotid artery. This condition is associated with an increased risk of neurological impairment, including stroke. Medical review further indicated that R1 had pre-existing conditions. There was no documentation indicating trauma or suspicious activity related to the fall. The attending physician did not attribute R1’s death to the fall. During the investigation, records review and staff interviews were conducted. Documentation reviewed indicated the facility followed the resident’s care plan. The facility implemented measures to address fall risk, including coordination with R1’s private insurance to request additional interventions, such as a bed alarm. At the time of the incident, alarms were in place and operational. Staff conducted routine checks, assisted with medication management, and addressed R1’s mobility needs, including the use of a wheelchair for transfers. On the day of the incident, documentation revealed that R1 received their prescribed medications, and routine checks were completed by staff. Based on the information obtained, there is insufficient evidence to support the allegation that the facility failed to provide adequate care and supervision. The allegation of neglect/lack of care and supervision is Unsubstantiated. Allegation #2 - Staff did not inform resident's responsible party of incident in a timely manner. Department staff conducted the investigation and revealed that at the time of the incident, the facility’s Medication Technician (Med-Tech) was notified by R1’s roommate that R1 had fallen. The Med-Tech responded immediately to the room and observed R1 on the floor. The MedTech initiated emergency response procedures. Vital signs were checked, and R1’s level of consciousness was evaluated. Emergency medical services were contacted without delay. Based on the information obtained, there is insufficient evidence to support the allegation that the facility failed to inform responsible parties in a timely manner. The allegation is Unsubstantiated . Regarding allegation #3 - Staff did not seek timely medical care for resident. Records reviewed during the investigation documented a dispatch time of 2101 hours. This documentation is consistent with staff statements and supports that emergency medical services were contacted promptly following the incident. The facility staff made timely notifications to the resident’s responsible party, and to the resident’s private insurance provider to address any additional preventive measures related to the incident. Based on the information obtained, the facility responded promptly and appropriately to the incident, including immediate assessment, timely contacting of emergency medical services, and required notifications. The allegation of neglect/lack of care and supervision is Unsubstantiated.