Incident investigation·September 4, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Director of Wellness (DW) Alexandra Matjunas. On 8/13/2025, the Department received a report from DW regarding resident R1. On 8/12/2025, R1's private companion (PC) noticed that R1 breathing changed and lip turned in blue color. PC notified the facility wellness center. The facility LVN went on site and 911 was called immediately. R1 was sent to hospital. LPA interviewed DW and Health Service Administrator (HSA) Bill Penrod. LPA requested R1's physician report, assessment, and progress notes. DW stated he/she will send R1's death certificate to CCL office when available. This case needs further investigation. Exit interview was conducted with DW. The report was provided to DW for review and signature. A copy of the report was provided to DW.