Facility Evaluation Report

At approximately 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management – Incident visit and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on incident report that were self-reported to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report from the facility on 02/22/2024. Report states that on 02/21/2024, Resident 1 (R1) was observed to have a stage two coccyx wound. Facility provided first aid. Facility made all appropriate notifications per regulation.

Per conversation with Administrator and Health and Wellness Nurse, R1 was observed to have the stage two wound on 02/21/2024. Per Physician communication, R1 is to be referred to Accent Care to receive an evaluation and specialist care. LPA was informed that Accent Care has already begun to oversee R1's wound care. Facility is communicating with Accent Care regarding R1's wound treatment and is documenting appropriately.

Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.