Incident investigation·October 2, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit at 10:30AM. The LPA met with Administrator Robloe (Rob) Babasanta and Director of Health Services Heather Hampel and explained the reason for the visit. Entrance interview conducted. The Department received a self-reported incident and a subsequent death report regarding Resident #1 (R1) on 09/15/2025. LPA requested documents for R1 be sent via email, which were received on 09/24/2025. Incident report indicates R1 was taking a walk with facility staff when R1 experienced chest pain and began to collapse. 9-1-1 was called and paramedics continued CPR, however R1 was pronounced deceased. During today’s visit, LPA conducted a brief physical plant tour to ensure there are no immediate health and safety concerns, conducted in-person interviews with Administrator and Director of Health Services and LPA obtained copies of pertinent documents relevant to the incident. Record review revealed R1 had a diagnosis of chronic atherosclerosis of aorta. Interview revealed about a week prior to the incident, R1 had visited the hospital and was medically clear to return to the facility. R1 had returned to regular activities and enjoyed taking walks multiple times a day. On the date of the incident, staff was with R1 when R1 collapsed, staff assisted R1 and began cardiopulmonary resuscitation (CPR.) Paramedics arrived and continued CPR, however, R1 was pronounced deceased. Following R1’s death, Administrator continued to communicate with R1’s family. Administrator provided LPA with email communication, which indicates R1’s cause of death was listed as “cardiac tamponade secondary to ruptured aortic aneurysm.” R1’s death was listed as natural. No citations issued. Should further investigation be warranted, LPA will return at a later date. Exit interview conducted. Report was reviewed and a copy was provided.