Incident investigation·September 8, 2022

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management pertaining to an special incident report (SIR) received to the RO, from the facility reporting that the facility having A/C issues. LPA met with Executive Director (ED) Susan Wesibarth, who was informed the reason of the visit. LPA also met and spoke with the maintenance director Erasmo Rodriguez. LPA conducted a physical plant and inspected rooms on the first and second floor of the building, including the Memory Care unit. According to the ED, about a month ago, there was a power outage and the A/C went down for a few hours and had to be reset. In recent events, on 09/02/2022, the A/C went out on the assisted living (AL) side on the second floor. The facility fixed the issue and it was repaired. For precautionary measures, the facility purchased fans for residents and requested a repairman to check the system and provide an estimate to install or repair the system. As of today's visit, the Administrator is still waiting for the estimate and has contacted another company which will come out on Saturday 09/10/2022 to provide details on what is needed to either repair or replace the system. The Administrator will submit estimate documents, as well as a plan of correction for the A/C to Licensing on Monday 09/12/2022. During the physical plant inspection, LPA checked several rooms on the first and second floor; including the Memory Care unit. Rooms were in compliance, according to Licensing regulations. The Administrator will report to Licensing regarding the plan to continue to fix the A/C. At this time, no further action is required, unless the system is not in working conditions or not in compliance.