Incident investigation·September 17, 2021

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management Visit. LPA met with and explained the purpose of the visit with Business Office Manager, Gladys Willhite and Administrator, Paige Williamson. The purpose of the visit is to follow up on the incidents that occurred on 6/17/21 and 8/7/21. Both incidents were reported to CCL by Special Incident Report (SIR). The incident that occurred on 6/17/21 resulted in Resident (R1) being absent without leave (AWOL) from the facility. LPA reviewed R1's Physicians Report, Milestone Assessment (Needs & Service) and staff In Service documentation. LPA observed window stop in place on R1's window as described in the SIR. The incident that occurred on 8/7/21 resulted in Resident (R2) and Resident (R3) having a physical altercation. LPA reviewed R2's Physician Report and Milestone Assessment (Needs & Service) which was updated after the incident on 8/22/21. R2 and R3 were roommates at the time. A room change was initiated, they are no longer in the same room. No deficiencies cited in today's visit Exit interview was conducted with Administrator