Incident investigation·September 22, 2023

Licensing Program Analyst (LPA) Steve Chang conducted a Case Management - Incident investigation visit to deliver the investigation finding and met with Executive Director Jud Severns (ED). On 07/05/2023, the Department received a death report of resident R1 from the facility that R1 was found dead at R1's bathroom on 07/01/2023. On 7/6/2023, R1's physician report and appraisal Needs and Service Plan were obtained. On the same day, LPA interviewed Resident Service Director (RSD). RSD stated on 07/01/2023, R1 was found on the floor of the bathroom and was unresponsive. 911 was called immediately. Paramedics came and announced R1 passed away. During 7/6/2023 and 9/12/2023, investigation was conducted. Based on the reviews of R1's medical records, the cause of the death of R1 was heart attack disease. Based on the interviews conducted and documents reviewed, R1's direct cause of death was heart disease. No deficiency or citation were issued today. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.