Follow-up·September 19, 2025

On 9/19/2025 at 9:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received for R1. LPA met with Administrator, Alicia Johnston and explained the purpose of the visit. Death report revealed that R1 was found unresponsive when staff went into R1's room for morning care. NOC shift staff heard R1 using bedside commode at around 1:00AM and staff check in on R1 at around 6:00AM. NOC shift staff observed R1 was sleeping. When morning staff found R1 unresponsive, 911 was called. Paramedics arrived and pronounced death at 7:33AM. LPA interviewed 2 staff and reviewed R1's file during inspection. R1's file revealed that R1 had a history of ischemic stroke, hypertension, and atherosclerosis of aorta. Staff stated R1 was happy and energetic the day before participating in games/activities. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.