Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to the facility at 1:45 pm. LPA was greeted and granted entry by the Concierge and met with Ashiman Gill, Administrator (AD) and LIbbie Retts, Director of Health Services (DHS) and stated the purpose of the visit

LPA interviewed three of three staff members regarding the Unusual Incident Report received in the Regional Office on December 23, 2024. LPA interviewed two of two resident family members.

LPA requested the following resident records: Identification and Emergency Information, Appraisal, Physician's Report, Physician Order Review, and Incident Progress Notes. LPA also requested staff files and the staffing schedule for care staff and engagement staff for December 20, 2024. LPA was also shown video footage of the incident.

Based on the interviews and observations made during today’s visit, LPA will need to further investigate the incident. An exit interview was conducted with Ashiman Gill, Administrator and a copy of the report was given at the time of the visit.