The deficiency at Sunplex Sub-Acute Center was one of 13 violations cited during the October 28 inspection.
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At Fortuna Rehabilitation and Wellness Center, federal inspectors found that system wasn't reliably there.
The inspection, completed on October 27, 2025, produced a citation under F0550, the federal tag that covers resident dignity and respect.
But inspectors determined the gap between what was happening and what should have been happening carried real potential for more than minimal harm.
The incident happened in the smoking room on October 21, 2025.
The resident at the center of the findings, identified in federal records only as Resident ID #3, did not survive.
The gap was documented in the facility's own staffing reports.
Federal inspectors who arrived at the facility at 14716 S.
The inspection, conducted on October 27, 2025, resulted in two deficiencies.
The admission came during a complaint inspection completed October 28, 2025.
What inspectors found wasn't a facility with no procedures on paper.
The violation came to light during a complaint inspection on October 27, 2025.