Incident investigation·August 16, 2022

At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case-Management Visit and met with Administrator, Carol Dowell. The purpose of the visit was to follow up on two self-reported incidents submitted to Community Care Licensing (CCL). Incident #1: LPA received an incident report on 8/15/2022. Incident Report stated that Facility Staff responded to an alarmed egress exit door and found Resident 1 (R1) outside. R1 was returned safely to facility. Facility made all appropriate notifications per regulation. Per discussion with Administrator, Facility notified family that a one-on-one companion would be needed due to R1's care needs. Facility provided and paid for one-on-one care but family refused to continue one-on-one care. R1 has since moved out of facility as of 8/11/2022. Review of alarm egress logs show that Facility Staff responded to Egress Alarm within 1 minute. Incident #2: LPA received an SOC-341 and incident report on 8/16/2022 regarding two residents that were in an altercation. Based on interviews and records reviewed, Facility Staff responded immediately and were able to separate residents. Residents were redirected with no further incidents. Facility has been redirecting residents successfully and have provided one resident with a key to their room to prevent future altercations. Facility made all appropriate notifications per regulation. No Deficiencies Cited during Visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.