Facility Evaluation Report

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to conduct a case management visit. LPA Williams identified herself to Administrator, Emelita Price who was also informed of the purpose of the visit.

On 9/30/2020, LPA Williams initiated a complaint investigation (Complaint Control #18-AS-20200928142900) and advised the Administrator that the investigation would be forwarded to the Department's Investigation Branch (IB). Upon completion of the investigation, Department staff identified that the facility had several violations that were not addressed in Complaint Control #18-AS-20200928142900. The following information was taken from the Investigative Case Report (RD #1820-09148):

Resident #1 (R1) experienced multiple falls while residing at the facility. A Needs & Services Plan dated 6/24/20, indicated that R1 was "subject to fall." However, the facility did not have a specific plan in place to prevent falls.

It was identified that R1 experienced several falls while residing at the facility; however, there was no evidence that the facility reported those falls appropriately. Staff #1 (S1) indicated to Department staff that they do not remember making the reports and they most likely did not report the falls.

According to medical records, R1 was "covered" in bed bugs upon arriving to the hospital on 9/17/20.

See deficiencies cited on LIC 809-D. An exit interview was conducted where this report was discussed and a copy was provided to the Administrator at the conclusion of the visit.