Incident investigation·June 15, 2021

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on multiple incident reports received by Community Care Licensing (CCL). LPA met with Director of Wellness Programs Ashley Croslin and explained the reason for the visit. Executive Director Melinda Forney and Nurse Managers Melissa Diaz and Cindy Fuentes were present as well. Incident reports dated 05/12/2021 indicated Resident 1 (R1) was sent out for elevated Biliruban and dehydration. Abrasion to right eye noted as well. Resident was diagnosed with Acute Renal Insufficiency, dehydration, and hyperkalemia. Resident is not noted to be a fall risk and resides in assisted living. R2 was assisted to the floor by caregiver after losing balance. No injuries noted and resides in assisted living. Incident reports dated 05/25/2021 indicated R3 was sent out for respiratory issues and is currently in the skilled nursing. Resident is independent. Incident reports dated 05/26/2021 indicate R4 sent out for hypertension and returned on daily checks on the independent side. R5 sent out after a fall on the independent side. R5 diagnosed with Congestive Heart Failure at the hospital and was admitted. Resident is back at this time. No injuries from fall noted. Incident report dated 05/30/2021 indicated 911 was called after R6 had a fall. R6 observed by paramedics who declined to transport. No injuries noted. No prior falls for R6 and fall precautions put in place as well as home health for physical therapy. Facility reported financial abuse for R7. R7 is donating money to random people and charities and falling victim to financial scams. Ombudsman informed as well as a prior report to Adult Protective Services. R7 currently manages own money however family is stepping in to take over finances. CONTINUED ON LIC 809C DATED 06/15/2021. During the visit, LPA consulted with the management team on visitation policies as well as personal rights for residents. LPA toured the assisted living as well as memory care unit and observed multiple outside visitation areas. No deficiencies noted during todays visit. Exit interview conducted and a copy of this report was left at the facility.