Complaint·May 5, 2023

Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial 10day complaint visit on 05/05/2023 at 10:54am. LPA met with Administrator Vanessa Jewell and explained the purpose of the visit. LPA conducted a physical plant tour at 11:03am. It is alleged that resident # 1 (R1) has never had a non-slip mat in their shower. LPA requested and obtained copies of facility files and documents including but not limited to staff and resident rosters at 11:52am. LPA interviewed Administrator and staff at approximately 12:03pm. Additional staff and resident interviews were conducted between 1:49pm to 3:00pm. During the investigation the administrator and staff confirmed they do not provide non-slip mats to residents. LPA observed thirteen (13) random bedrooms and two (02) out of (13) were observed to have a two (02) non-slip mats in the bathroom shower. Based on inspection, observations and interviews there is enough evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED at this time. No health and safety hazards are noted during this visit. Deficiency cited, Exit interview conducted, and copy of report and appeal rights issued.