Incident investigation·June 4, 2025

Licensing Program Analysts (LPA’s) Erica Mosley and Kelly Dulek conducted an unannounced Case Management – Incident visit at 11:00 a.m., The LPA’s met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted. The Department received a self reported incident report and a subsequent incident death report regarding Resident #1 (R1) on 05/12/2025 and 05/13/2025. During today’s visit, LPA's conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted in-person interviews with the Executive Director (ED), six (6) staff members, attempted three (3) resident interviews, conducted two (2) resident interviews along with obtained copies of pertinent documents relevant to the incident. If further investigation is needed the LPA will return at a later date. Exit interview conducted. Report was reviewed and a copy was provided.