Facility Evaluation Report

On 9/14/23 at approximately 1:40 pm Licensing Program Analyst Jennifer Fain and Licensing Program Manager Liza King arrived at the facility to conduct a follow up Legal Noncomplaince Case Management Visit from 8/25/23. LPA and LPM met with Stephanie Siewe and explained the reason for the visit.

On 8/30/23 LPA Fain received requested documents: 602s for all residents and the facility sketch.

During the Informal Meeting on 4/12/23 the licensee agreed to “evaluate the current STD850 to ensure that they are in compliance with the state Fire Marshall; The facility has a non-ambulatory fire clearance for each room that will be used to accommodate a resident with dementia within 2 days; submit an updated LIC200 and facility sketch.”

Based on the 602’s supplied for the residents, the facility sketch, and rooms the residents are staying in (provided by S1 on 8/25/23), there are 8 non-ambulatory residents , 4 of them are in ambulatory rooms.

Also, during the Informal meeting, the Licensee agreed to “Conduct a self-assessment of all resident and personnel files within 30 days and make needed updates per requirements.”

Based on the 602’s received 4 of 6 are past the due date for the required one year health evaluation.

LPA requested Discharge papers for R1 from hospital visit on 8/5/23 and related SIR.

LPA requested Incident Reports and discharge papers for R2 for the months of June, July and August 2023.