Facility Evaluation Report

Licensing Program Analyst (LPA) Olson conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20230213084818). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-20230213084818, the following deficiency was observed: Facility personnel complete records for Staff #1 (S1) were not available for the Community Care Licensing (CCL) Investigation Branch (IB) Investigator Santiago to inspect, audit and copy during the initial visit to the facility on 03/16/2023 and subsequent visit on 03/17/2023.

Facility also did not submit incident reports to CCL. On 2/14/23 LPA requested all incident reports related to the complaint and was given 4 incident reports dated 9/5/22, 9/7/22, 9/10/22 and 9/15/22. LPA reviewed incident reports sent to CCL and observed the last incident report the facility sent was received 5/4/21 dated 5/1/21 for a medication error. Administrator stated they didn't know they had to send them and asked where to send incident reports, LPA provided CCL's fax and email.

Citations issued, exit interview, copy of report, appeal rights were printed and emailed.