Facility Evaluation Report

At approximately 10:15 AM on 02/11/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced initial complaint investigation. LPA met with Administrator and disclosed the reason for the visit.

During the course of the complaint investigation, LPA found deficiencies. LPA was greeted at the door by an individual without a criminal background clearance.

Administrator was not present at the facility when LPA arrived, and only the individual was present. Both the individual and Administrator stated the individual was supervising residents in care because the Administrator felt ill.

LPA reviewed records for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4).

Resident records of R1, R2, and R3 did not contain Physician Reports or reappraisals within the past 12 months.

LPA conducted exit interview, issued civil penalties, discussed appeal rights, and issued report.