Facility Evaluation Report

On 11-16-23 at 3:45pm meeting was held via Microsoft teams to review the facility's compliance with the quarterly visits. Present at this meeting were Licensing Program Analyst (LPA) Michael Bilger, Licensing program manager (LPM) Liza King, Ombudsman Kathryn Thomas, and Licensee Adetayo Kokumo. Topics discussed in this meeting included physical plant, incident reporting, medication procedures, record keeping, resident rights, care and supervision, and staffing levels. LPA and LPM discussed with Licensee the facility’s current absence without leave (AWOL) procedures. At this time, licensee states 2 staff are on duty at all times. In addition, to ensure whereabouts of residents at all times, Licensee has initiated a checklist for staff to complete noting the location of residents in care. Previous AWOL incidents were discussed. Additionally, Licensee stated a signal system has been placed on the door to alert staff of individuals exiting and entering facility. Licensee will continue to complete all initial and on-going staff training per regulations and continue to maintain appropriate updated resident records including needs and service plans, appraisals, and medication documentation.

At this time the department finds the facility to have been in compliance with the requirements for the quarterly visits and the department has no concerns regarding the facility at this time. Therefore, the quarterly visits will cease. Additionally, the Department has lifted the requirement of Administrator of Record on duty at least 40 hours per week previously imposed. Licensee was made aware that Administrator must be present in facility a sufficient number of hours to meet the needs of residents in care.

An exit interview was conducted with Adetayo Kokumo and a copy of this report was emailed to Adetayo with request for return with signature.