Incident investigation·September 16, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Director of Wellness (DW) Alexandra Matjunas. Today's visit is to follow up with the case management visit on 09/04/2025. . On 8/12/2025, resident 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. On 08/12/2025, at 08:55AM, R1 passed away in the hospital. On 09/04/2025, LPA conducted an unannounced case management visit at the facility. LPA interviewed DW and Health Service Administrator (HSA). LPA requested R1's physician report, assessment, and progress notes. On 09/09/2025, LPA received R1's death certificate. Based on the review of R1's death certificate, R1's cause of death is heart disease, natural cause. Based on the interview and records reviewed, there is no suspicion of R1's death. No citation noted today. Exit interview was conducted with WD. The report was provided to WD for review and signature. A copy of the report was provide to WD.