Facility Evaluation Report

Licensing Program Analysts (LPAs) Melissa Parks and Lavinia Muscan arrived on Wednesday April 5, 2023 to conclude the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs did not find current reappraisal forms for residents R1 and R2. LPAs observed minimal food in facility's pantry (pictures taken). Facility Administrator has excess food kept in a locked garage at a sister facility, which is inaccessible to facility staff. While reviewing staffing schedules, LPAs learned that staff do not provide care for residents between the hours of 10pm and 6am. Currently, there are two residents who require incontinence care. Deficiencies cited on 809-D.

Exit interview conducted. Appeal rights given to Administrator. A copy of this report was emailed to the Administrator.