Facility Evaluation Report

On 12/9/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a Case Management regarding a report received from the facility alleging former staff (S2) married current resident (R1). LPA met with Caregivers S3 & S4. The staff called the Administrator and informed him the purpose of the visit. Administrator stated to provide copy of report to S3.

During the case management visit, LPA conducted staff interview and attempted to interview R1. LPA requested copy of R1’s file including but not limited to admission agreement, R1’s physician’s report, R1’s incident report for the last six months, R1’s financial documents document, six months facility’s residents outgoing and incoming log, three months staffing schedule and S2’s staff file; these documents needed to be submitted on or before 12/12/2022

Due to insufficient information at this time, LPA will conduct additional interviews and documents reviews. LPA will return to the facility.

Exit interview conducted with S3, copy of report was provided.