Facility Evaluation Report

Regional Manager (RM) Reyna Lacey conducted an onsite visit and met with Tari Lewis, Administrator and Licensee. During the visit, it was discovered the facility is retaining two residents who are bedridden.

Physician reports, hospice care plans and interviews were conducted. Facility staff confirmed both residents are assisted with repositioning. Hospice care plan for Resident 1 (R1) indicates R1 is bedbound. Pre-placement Appraisal dated 04/29/25 for R1 indicates bedridden.

Hospice care plan for R2 indicates bedbound. Physician Report dated 12/07/2023 indicates R2 is bedridden.

This facility does not have an approved fire clearance to accept or retain bedridden residents.

A deficiency was cited and a civil penalty was assessed in the amount of $500. An exit interview was conducted with Nikita Leiws where this report, the LIC809D, and LIC421 civil penalty assessment form was reviewed. Appeal Rights were reviewed and provided.

Due to technical issues, the report and forms will be emailed to the licensee/administrator.