Facility Evaluation Report

On 6/26/2025, Licensing Program Analysts(LPAs) John Calandra, Simi Rai, and Manuel Monter, arrived at the facility to conduct a Case Management visit to cite additional deficiencies discovered during the Department's investigation of a complaint #14-AS-20250417161453 received on 4/17/2025. LPAs were greeted by Fe Arnaiz (ADM1) and William Zach Pilkerton (ADM2), and explained the purpose of the visit.

During the visit, LPAs toured the physical plant inside and outside. LPAs reviewed 32 resident files (R1-R32) including Centrally Stored Medication Records, Medication Administration Record (MAR) for January 2025 - March 2025 and centrally stored medications at the facility.

Based on the review of R1's Physician's report dated 9/3/2024 which stated R1 has a dual diagnosis of Mental Illness and neurocognitive disorder. Based on review of the facility's plan of operation page 16, "residents determined by their physicians to have a primary diagnosis of mental disorder unrelated to Dementia shall not be accepted or retained." R1 was admitted to the facility on 11/11/2024.

On 3/6/2025, Staff S4 was interviewed. Staff S4 stated, he/she conducted a routine check at 4:00am where he/she observed R1 to be in his/her room lying on his/her bed. Based on evidenced reviewed, resident R1 was observed outside of the facility at 1:38am-4:47am. Staff did not observe resident during this time frame. A Type A citation was issued for this violation during today's visit.