Facility Evaluation Report

Licensing Program Analyst (LPA) Katie Brown conducted an unannounced Case Management – Deficiencies visit. LPA met with and explained the purpose of the visit with April Gaylord.

The purpose of the Case Management is to follow up on the Restricted Health Condition Care Plan (CP) for R1. During the Annual visit on 12/5/22, LPA requested to review the CP and Physician's Report of R1. Neither of the documents were located in the file. AD did not submit a complete CP to LPA for review.

Deficiencies for Restricted Health Condition Care Plan is being cited on the attached LIC9099-D.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with April Gaylord, whose signature on this form confirms receipt of these documents.