Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Deficiency visit in conjunction with a subsequent complaint visit (CC #29-AS-20240417093431). LPA met with Sales Director Ty Henson and explained the reason of the visit. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint allegations.

On 05/12/2025 at approximately 11:30 a.m., the LPA observed a resident in the outside courtyard of the Memory Care Unit that is attached to the dinning area of the residents. The doors to the courtyard were open. As staff and residents were getting ready for lunch, several residents began to complain about being cold and a resident went to close the glass door leading to the court yard. After a few minutes the resident that was outside attempted to open the door, and was not able to as the door was locked. The resident became agitated and started pounding on the door, a guest who was visiting went to open the door for the resident and opened the door with a fob. The resident was noticeably upset and yelling at the guest that they had locked them outside. The guest attempted to calm the resident down. The LPA informed staff the courtyards doors cannot be locked as residents can get locked outside. Staff stated that the doors are usually locked from the outside and can be opened with a fob, however residents do not have a fob. After being notified of the incident the Administrator had maintenance fix the door and unlock it from the outside in.

Report will continue on LIC809-C, 2ND PAGE..