Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit to document deficiencies observed during the investigation of complaint 22-AS-20241118163642 but unrelated to the allegations investigated.

During a tour of the physical plant and subsequent review of resident records, LPA observed that all four residents were non-ambulatory and that all four were admitted onto hospice and currently receiving hospice care. However, based on the terms of its license, the facility has a fire clearance for three ambulatory and three non-ambulatory residents along with a hospice waiver for three residents. Licensee is therefore in violation of the terms of its license along with its hospice waiver.

Two type A citations are issued during the present visit. An exit interview was conducted and a copy of this report was provided to a facility representative.