Facility Evaluation Report

Licensing Program Analyst (LPA) Olson conducted an unannounced case management visit to issue a deficiency. LPA Olson received multiple Incident Reports (IR) from the facility that were sent after the required 7-day time frame. LPA provided courtesy reminder emails to the Administrator on 3/30/2022, and to the Administrator and Wellness Director on 5/27/2022. LPA continued to receive Incident Reports late, including:

· On 6/7/2022, LPA received IRs from 5/22/2022 (16 days after incident), and from 5/18/2022 (14 days after incident).

· On 6/23/2022, LPA received IRs from 6/15/2022 (8 days after incident), 6/14/2022 (9 days after incident), 6/13/2022 (10 days after incident).

· On 6/29/2022 LPA received IRs from 6/19/2022 (10 days after incident), 6/18/2022 (9 days after incident) and 6/17/2022 (8 days after incident).

Based on the information obtained, the facility is cited for late reporting.

Exit interview, report given, deficiency cited on 809-D, appeal rights given.