Complaint·January 27, 2022

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Emelda Good and discussed findings. Complainant alleges that R1's death is questionable due to facility staff's failure to obtain timely medical care; facility's failure to provide sufficient nourishment for R1; and that the refrigerated medications were not kept secure. This Department's investigation has included site visits to facility; review of documents; and statements from staff and witnesses. The following determinations are made: R1 left the facility on 10/20/2021 for emergency care and did not return; R1 died on 11/05/2021 while in skilled nursing; Cause of death was determined to be from an incurable illness from which R1 suffered for many years and Alzheimer's Dementia; Staff report that R1's condition was stable on the days preceding her hospitalization although R1 was sleeping more and eating less but was alert; No refrigerated medications were stored at time of site visits; all staff report the medications were kept secure; Facility notes and records suggest that R1 was monitored by staff and that medical care was obtained when staff noted change in condition of R1. Although the allegations may be true, or valid, based upon observations, statements, and records, there is not a preponderance of evidence to prove the allegations are, or are not, true. Therefore, allegations are UNSUBSTANTIATED.