Facility Evaluation Report

Licensing Program Analyst (LPA) Coppo arrived unannounced to conduct this Case Management Visit to follow up on incident reports and a death reported received by the facility. LPA met with Administrative assistant Jeralyn May. Licensee Alex Varshavsky arrived later.

On 10/19/25 facility submitted an Incident Report for resident R2 indicating that on 10/17/25 R2 was found in their room shaking. Emergency Medical Services (EMS) were called and R2 was taken to the hospital. R2 was seen for a new seizure like activity, dehydration, and a urinary tract infection (UTI). A follow-up appointment was scheduled for 12/2/25. On 10/30/25 the facility submitted an Incident Report for R2 indicating that on 10/29/25 R2 was observed to have a dark colored urine, presenting as weaker than baseline, and seemed more confused than baseline. The facility called EMS and R2 was taken to the hospital. On 11/10/25 facility submitted a Death Report for R2 stating the date of death as 11/2/25 with the immediate cause listed as cardiopulmonary arrest. Conditions prior to or contributing to death were listed as septic shock due to urosepsis/UTI with underlying cause: acute metabolic encephalopathy.

On 12/8/25 facility provided R2's Death Certificate to CCL for review. Review of Death Certificate shows causes of death and underlying causes to be the same as facility listed on death report submitted: immediate cause listed as cardiopulmonary arrest. Conditions prior to or contributing to death were listed as septic shock due to urosepsis/UTI with underlying cause: acute metabolic encephalopathy.

During case management visit, LPA reviewed chart notes and conducted interviews. Per R2's chart notes on