Facility Evaluation Report

Licensing Program Analysts (LPA)'s Shawna Doucette and Darius Williams arrived at the facility unannounced to commence and complaint investigation and deliver findings for Complaint AS-20230321111428 and Complaint 24-AS-20230330093440. LPA's met with Administrator Douglas Rice.

During the course of the investigation LPA's observed the following deficiencies. LPA requested records for the signal system for 3/15/23 to 03/31/23. Administrator stated he was unable to provide those records due to the system recording over every 2 days. During the course of the investigation after interviewing witnesses it was found the records are permanent and do not erase.

LPA was unable to locate an incident report for R1 regarding incident in complaint 24-AS-20230330093440. LPA requested copy of the incident report for R1 while at the facility. Resident Care Coordinator Emily Conrad and Administrator Douglas Rice were unable to provide a copy of this incident report. Resident Care Coordinator stated facility does not have an incident report for this incident.

An exit interview was conducted with Administrator Douglas Rice and a copy of this report was provided with plans of corrections and appeal rights.