Facility Evaluation Report

On 3/10/2023 at 9:45, Licensing Program Analyst (LPA) Melissa Spaeth arrived at the facility to conduct an unannounced case management visit. The purpose of this visit was to determine if the deficiencies cited on the previous case management visit that took place on 3/2/2023 by LPA Ruiz, Regional Manager Kendrick and LPM Gillyard had been corrected.

LPA and Licensee toured the facility at 10:00 am until 10;15 am. LPA observed a resident (R1) was in bedroom but no caregiver was present. Licensee stated stepped out for a few minutes. LPA stated that residents are not to be left alone within the facility.

During LPA's visit, LPA reviewed the following deficiencies with the License:

The licensee did not provide an update that six out of six client records were updated and that accurate documentation is located in each client file. Proof of correction was not provided to LPA by the POC date of 3/09/2023.

The licensee did not provide documentation that staff 1 completed a TB test. Licensee was unable to provide the documentation. Proof of correction was not provided to LPA by the POC date of 3/04/2023.

The licensee did not purchase sufficient food, did not provide a copy of receipt and did not provide photo documentation of sufficient food to the LPA. Proof of correction was not provided to LPA by the POC date of 3/04/2023.

The licensee did not submit a plan to hire additional staffing. Proof of correction was not provided to LPA by the POC date of 3/04/2023