Follow-up on corrections·April 8, 2026

This case management visit conducted by Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan due to increased complaint volume, prior issues observed to include but not limited to insufficient staffing . Upon arrival, licensing representatives observed the following: · The facility did not have sufficient support staff. · LPA Smith and LPM Margaryan observed no front desk staff present. They remained at the front desk for approximately 20–30 minutes before a maintenance worker arrived to assist. · On 04/06/2026, LPM Margaryan conducted a follow-up call with the Executive Director (ED), who confirmed that the facility does not currently have an employee assigned to the front desk. · The facility continued to lack adequate staffing to meet residents’ needs. During the licensing visit on 02/27/2026, LPA Smith and LPM Margaryan detected a strong urine odor in the elevator, third-floor hallways, and common areas. They observed a resident in a wheelchair who was wet and emitting an odor of urine, and/or feces. On the third floor and throughout the facility, only one caregiver was on duty to provide care and supervision for all residents. (cont from 809C) Based on observations and interviews with residents and staff, nine residents required extensive care. Three residents in wheelchairs, who required escort assistance, were left without supervision. At least one resident required a two-person assist for transfers in and out of bed/chairs/toileting and/or showering. Emergency Plan Review · The facility’s Emergency Plan of Operation was reviewed and requires updates. · Non-ambulatory residents were observed on the third (3rd) floor, and it was not clear how staff would assist them during an emergency. · To date, no updated emergency plan has been submitted to the Licensing office for review and approval. Resident Records Review · Residents’ records were incomplete and/or outdated. · At least one (1) resident assessment contained conflicting information regarding the level of care required (e.g., bathing, toileting, dressing) when compared to medical assessments. · At least one (1) resident file did not contain the Administrator’s/Director’s signature and date on required documents, including Resident Appraisals and Needs and Services Plans. · No written notification was provided to the Licensing office verifying that all resident records had been updated and corrected. Deficiencies cited on the LIC 809D. Exit interview conducted, appeal rights discussed, copy of the report given