Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct an annual continuation visit, as well as a concurrent case management visit. Upon arrival, the LPA met with Interim Administrator Laken Lacy. Entrance interview conducted.

This visit and related report serve as the annual continuation, legal non-compliance, and case management - incident visit. The purpose of today’s legal non-compliance visit is to ensure the facility is maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The last legal non-compliance visit took place on 08/01/2023.

Upon arrival, LPA met with Interim Administrator and further discussed an incident report that was sent to Community Care Licensing on 09/04/2024, although it was not received and discussed until an unrelated visit at the facility on 10/16/2024. The incident report relates to an allegation made by Resident #1 (R1)'s private companion on 09/03/2024. However, the report referred to an allegation of sexual abuse R1's private companion stated they first observed in March 2024. The facility provided LPA with additional documentation relating to R1, including but not limited to suspected abuse report and medical documentation. R1's family member, who is a medical professional, had R1 tested and no evidence of sexual abuse was found. At the time of the alleged observation/suspicion of abuse, R1 had been diagnosed with a UTI. R1 does have a diagnosis of dementia, so R1 is unable to coherently verbalize any concerns. Interim Administrator stated that following the allegation, both of R1's private companions were provided coaching on timely mandated reporting. After reviewing all information obtained, should a further visit be warranted, LPA will follow up with the facility.