Incident investigation·July 14, 2023

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management-Incident visit and met with Administrator (ADM) Bani Kaur. Today's Case Management-Incident visit continued 10/26/2022 Case Management-Incident investigation visit. On 10/18/2022, the Department received an incident report regarding a resident (R1) who fell and died in the bedroom on 10/18/2022. 911 was immediately called when staff found R1 in bedroom floor. On 10/26/2022, the Department interviewed 4 residents (R2-R5), 2 staff (S1-S2), and ADM. R1's physician report, Appraisal Needs and Service Plan, medical records were obtained and reviewed. Based on the review of medical records of R1’s cause of death, R1’s cause of death is due to heart disease and other underlying medical health issues. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.