Facility Evaluation Report

On September 4, 2024, Licensing Program Analyst (LPA) Murial Han and Komal Charitra conducted an unannounced plan of correction visit to follow up on a civil penalty that was assessed on 8/20/2024. LPA met with caregiver, Doris Mores and explained the purpose of the visit. The administrator arrived shortly thereafter and assisted with the visit.

On 8/ 20/2024, LPA Han conducted an unannounced Plan of Correction visit to follow up on the citations that were issued during the annual inspection on 8/6/ 2024. During the visit, LPA reviewed and validated the plan of correction that was submitted by the administrator/licensee and cleared 9 out of 12 citations However, LPA observed the remaining citations- 1569.695(c) ; 87608(a)(5)(B); 1569.625(b)(2) were not corrected and due to the citations not being corrected, a civil penalty in the amount of $3300 was assessed from 8/8/2024 - 8/20/2024.

During today's visit, LPAs reviewed the plan of correction for the following citations:

- 1569.695(c)- Emergency drill was conducted on 8/23/2024 and the administrator stated that it will be conducted on a quarterly basis.

- 87608(a)(5)(B)- Physician orders were obtained for the residents who have a bed rail by the head of the bed.

- 1569.625(b)(2)- Annual training was started for staff on 8/30/2024 and will continue.

Civil penalty is being stopped on 8/21/2024 as the above citations are observed to be corrected.

No deficiency is cited today. This report is reviewed and discussed with the administrator and a copy is provided.