Facility Evaluation Report

Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240214112429 ). LPA met with Executive Director Nancy Nelson and explained the reason for the visit.

During the Department’s investigation of complaint # 29-AS-20240214112429, the following deficiencies were observed:

A review of the facility notes revealed that on several dates (11/10/2021, 12/22/2022, 02/25/2022, 02/08/2023, 03/28/2023, and 04/04/2023) Resident #1 (R1) had unwitnessed falls which required visits to the Emergency Room. There were no incident reports submitted to Community Care Licensing (CCL) for the dates noted.

On 07/30/2023, after an unwitnessed fall in the bathroom, R1 suffered facial swelling on the right side and a skin tear to chin and was admitted to the hospital. R1 was placed on Affinity hospice and discharged back to the facility. The facility did not submit a hospice notification to CCL.

Citations issued, exit interview, appeal rights given.