Facility Evaluation Report

At on 11/21/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit related to a complaint finial findings (29-AS-20241104143354) visit being issued on this same visit. LPA met with announced who he is and the reason for the visit.

During the above-mentioned complaint, it was discovered through interviews on 11/05/2024 Licensee/Administrator stated on 11/04/2024, facility staff accidently gave Emergency Medical Technicians (EMT’s) Resident 1 (R1) full resident file, containing documents including but not limited to Pre Admissions Appraisals, Appraisals Needs and Services Plan, Admissions Agreement, Hospital and Physician Visit, Home Heath Care documentation and other documentation. Licensee/Administrator made several attempts to located R1’s file including Calling both hospitals, EMT company, Placement Agency, and R1’s son. On 11/18/2024, Licensee/Administrator sent LPA Jeffries and email that R1’s file was, “nowhere to be found.” On 11/17/2024 LPA Jeffries contacted Licensee/Administrator by phone and requested Incident report for R1 for 11/04/2024 hospitalization and death report for same date. Licensee/Administrator stated, “I was so nervous, I forgot”. Licensee emailed LPA Jeffries incident report on 11/17/2024, and an informal email stating that, facility was “Waiting for the Death Certificate from The Coroner's office to provide a copy.” LPA noted that on 08/29/2023, during a prior complaint investigation, and 12/12/2023 during an annual inspection, and an email on 08/14/2024, the regulation requirements for timely reporting, including where, who and how to report. LPA noted that the incident report and the death report were not submitted to LPA’s email until 12 days after the incident and death. Additionally, Licensee/Administrator did not safeguard Resident information and Resident files to keep for 36 months. LPA noted that the facility is cited for Reporting Requirements [87211(a)(1)(A)]. LPA noted that facility is cited for Resident Records [87506(c)(1) and 87506 (e).]

Exit interview, report read, appeal rights and report provided .