Facility Evaluation Report

A meeting was held with licensee to discuss a Technical Support Program Engagement Summary (TSP) generated on 01/28/2025. This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, LPA Noel Wolf Petersen, \ Ombudsman Kathryn Thomas. and Licensee Monica Plowden. At the beginning of the meeting, Licensee confirmed receipt of TSP material from visits on 01/10/25 and 01/28/25.

LPM discussed the following topics previously addressed at the TSP Engagement:

Personnel / Training In regards to personnel training, licensee has a staff training log already in use and conducted the training's required as part of the informal conference during the month of December 2024.

Medication Management The licensee was provided resources, however currently uses Alcame for medication management which allows for audits and quality assurance checks. Therefore, the monthly medication audit and medication room organization guide will not be implemented but may be used as a resource in the future.

Record Keeping the licensee reported that there is already a checklist implemented for personnel and resident files.

LPM confirmed resources and tools documented in the engagement summary were provided to the licensee. Since links were not provided in the document, LPM will forward them via email.

No citations were issued, a copy of this report was delivered via phone and email.