Incident investigation·November 4, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit at 02:07PM. The LPA met with facility staff. Administrator was contacted and arrived at 02:25PM. Entrance interview conducted. The Department received a self-reported incident and death report regarding Resident #1 (R1) on 09/15/2025. LPA requested documents for R1 be sent via email, which were received on 10/27/2025. Incident report indicates that on 10/23/2025, R1 was experiencing shortness of breath, 9-1-1 was contacted and R1 was subsequently taken to the hospital. Death report indicates R1 passed away on 10/25/2025 at the hospital, however no additional information was provided. During today’s visit, LPA conducted a brief physical plant tour to ensure there are no immediate health and safety concerns, conducted interviews with Administrator and staff and LPA obtained copies of pertinent documents relevant to the incident. Record review revealed R1 was admitted to the facility on 09/26/2025 after being discharged from a Skilled Nursing Facility. Interview revealed R1 was admitted to home health services and a nurse visited the facility twice a week to care for R1's health needs. Interview further revealed that on 10/23/2025, R1 had been coughing and had excess phlegm since the morning and the nurse visited that afternoon. Later that evening around 09:00PM, the resident experienced shortness of breath and at approximately 11:30PM, R1 was taken by ambulance to the hospital. The LPA informed Administrator that either LPA or Investigations Branch (IB) Investigator will follow up related to R1's death. No citations issued. Exit interview conducted. A copy of the report was provided via email.