Facility Evaluation Report

Licensing Program Analyst Manuel Monter conducted an unannounced case management- deficiencies , regarding violations discovered during the complaint investigation for 26-AS-20250929092054. LPA met with Administrator Jolie Higgins

During complaint investigation, The Department reviewed R1's progress notes. Progress note dated March 12, 2025 states, R1 is doing well after elopement. R1 did not him/herself, no injuries noted. R1 stated he/she was accompanied by a woman and that all he/she did was push buttons and stepped foot into the elevator. R1 went to receptionist and concierge alerted nurses.

The Department reviewed resident R23 and R24's Progress notes. Progress note dated March 2, 2025 states staff S11, Heard commotion in the hallway. R23 was noted in the hallway in front of apartment door. Two residents were in the hallway being separated by 3 care givers. 1 care giver informed S11 that R24 had a knife and was trying to stab R23. S11 redirected R24 to his/her apartment.

On February 25, 2026. LPA Manuel Monter requested documentation for the incident reports that were sent for the two incidents noted on the progress notes. LPA was informed on February 25, 2026, that the facility does not have documentation for both of these incidents.