complaint·July 11, 2024

Continued from 9099... Progress notes reviewed as part of the investigation show that resident was eating less food and refusing medications due to the pills being too large to swallow. Resident’s doctor was faxed to request an order for pill crushing. Per staff interviews, resident had been on a decline for approximately one year and showed signs of a low appetite in addition to refusing medication. Due to resident already declining, there was no identified change of condition which warranted further medical intervention. Per evidence obtained during investigation, on the day that resident passed away they requested Tylenol due to complaints of a headache. Staff attempted to transfer resident to their wheelchair when they became unresponsive. Resident was placed back in bed and 911 was called. Resident passed away at the facility due to Major Neurocognitive Disorder (Dementia), Type unspecified without Behavioral Disturbances. Other significant factors in the case of death were listed as, Atrial Fibrillation, moderate protein calorie malnutrition, diastolic heart failure, chronic community acquired pneumonia. Based on record review and inconsistent statements provided during interviews, CCL is unable to determine if violations occurred. Therefore, the allegations are Unsubstantiated. A finding that the complaint is 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.