complaint·April 12, 2022

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit. LPA conducted a physical plant tour to ensure no immediate health and safety issues from 10:45-11:15pm. No immediate health and safety issues were noted. LPA observed staff to be wearing mask throughout the facility and hand sanitizers were available throughout the facility. LPA conducted the intial visit on 4/1/2020 where interview was done with the administrator. It is alleged that facility staff failed to wear mask consistently around the facility and were not ensuring that residents were social distancing from one another. Since this complaint came in facility had an annual visit on 8/3/21 and a case management visit on 10/5/21. During both visits it was noted that staff were not wearing mask properly and that residents were not observed to be social distancing by the LPA's who conducted those visits. Deficiencies were cited on both visits and since then deficiencies have been cleared. Due to those visits happening after this complaint came in this allegation is deemed Substantiated however no deficiency will be cited due to the facility already correcting the deficiencies issued on visits on 8/3/21 and 10/5/21.