Follow-up·October 18, 2024

At 8:30 a.m. on 10/18/24 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Today’s case management visit was conducted to survey the facility for appropriate areas to designate for smoking as well as to address any areas of noncompliance and provide guidance. LPA and LPM conducted a facility tour at 8:30 a.m. and noted the following observations: The door to a maintenance storage area near the garage was open. The hallway to the maintenance storage area had a small tripping hazard and a blemish on the wall. Tour of the courtyard revealed some unused items like a pedestal and some cans needed to be disposed. Two (02) screen doors leading to the courtyard needed to be fixed. A face plate in the culinary director’s office area needed to be remounted. The recently repaired area in the kitchen needed to be retiled. Lastly, the laundry area was accessible and unattended. LPA and LPM addressed these concerns around 9:45 a.m. with the administrator and the Vice President of Operations. LPA and LPM also discussed plans for carpet cleaning or flooring renovations, staff training procedures, laundry procedures, ensuring residents’ abilities to attend appointments, and a plan for updating resident, personnel, and facility files. The facility plans to gradually improve all areas of operations within reasonable time frames. Also, the administrator agreed that all facility files can be updated by the end of November 2024. LPA will return at that time to audit files. No deficiencies are assessed at this time. Exit interview conducted. Copy of report provided.