Facility Evaluation Report

In conjunction with complaint control # 31-AS-20240716123550, Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to address an incident regarding elements of care and supervision. it was reported that the facility didn't have a required staff, or nurse, on shift, on 06/08/24 and 06/14/24. According to the facility's program design, "an LVN shall remain on duty until relieved by incoming staff". Report received by another government agency reveal that on 06/08/24, Staff 1 (S1), called off, and Staff 2 (S2) was called to provide coverage. However, S2 left at approximately 9pm, which entails that the facility failed to follow their contingency plan, identified the facility's Program Design. Based on this information received, the facility failed to provide services and coverage on 06/08/24 and 06/14/24, to address the needs of the residents in care. This incident was addressed on the above mentioned control number. Citation will be issued on the 809D, and cleared to reflect this CM visit. No further corrections required at this time. Administrator advised, and a copy of this report issued.