Facility Evaluation Report

On 3/7/24 at 10:30am, Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility to conduct an unannounced Plan of Correction (POC) visit. LPA initially met with the staff on duty and explained the purpose of the visit. Chukwudi Isikeh, administrator, was notified of the visit by the staff. Staff on duty was given permission to sign this report. The purpose of this visit was to verify the plan of correction that was required to be completed on ____ for deficiencies that were previously cited on a prior visit conducted on 11/27/2023. Present during this visit are 3 residents in care with 1 staff on duty.

During this visit, LPA attempted to conduct file reviews of the 4 staff noted on the LIC 500 dated 11/25/23. Staff on duty was only able to retrieve 2 staff files for review at this time. Per staff on duty, the files for the administrators are not present at this facility. Additionally, per interview of staff on duty, staff_1 (S1)noted on the LIC 500 dated 11/25/23 is no longer employed at this facility. LPA also requested S1's files for review but staff on duty is unable to retrieve and stated it is not at this facility at this time.

LPA also reviewed resident files and found that resident_1(R1) is using a catheter. Per interview with R1 and staff on duty, it was revealed that R1 is unable to care for their catheter and requires staff assistance at this time. Per interview with Chukwudi Isikeh, a request for an exception for R1's catheter has not been submitted to the Department for approval. Further resident file review revealed that R1 does not have Needs and Services Plan (LIC 625) in their file.

LPA requested from the facility to submit an updated LIC 500 to the Department.