Non-compliance follow-up·November 13, 2024

At 08:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced Case Management Visit. LPA met with Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit. On 02/29/2024, a Noncompliance Conference was held at the Regional Office (RO) with the Administrator and concerns from Complaints #31-AS-20240110162135 and #31-AS-20230605162033 were addressed. At that time, Regional Manager (RM) and Licensing Program Manager (LPM) advised the Administrator to conduct thorough pre-admission appraisals and complete staff training. The purpose of todays visit is to review all resident and staff files for an accuracy. LPA was informed that the facility currently has five (5) residents. Facility also has two (2) staff members and LPA checked the Licensing Information System (LIS) and observed that both staff members are associated with this facility and the fingerprints are cleared. Resident Files: At 9:45am team conducted resident and staff records review. The following was observed. Five (5) out of five (5) resident file were available and LPA observed all files were signed and complete. Staff Files: Administrator stated that the facility currently has four (4) staff members. LPA observed two (2) out of four (4) staff members present during today's visit. LPA conducted review of staff records and observed all required training along with staff signed and complete records on file. No deficiency cited. Exit interviewed conducted and copy of this report signed and delivered.