Follow-up·February 7, 2025

At 11:00 a.m. on 02/07/25 Licensing Program Analyst (LPA) Nicholas Reed 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 in conjunction with a complaint visit for complaint # 31-AS-20250205150035. During the course of investigation, a deficiency was discovered involving the facility’s Activity Director (AD). Interview with the AD at 11:05 a.m. today revealed they were sent to drive the facility van yesterday, 02/06/25, to ensure a resident attended their medical appointment. The driver that the facility recently hired, Staff #1 (S1), was busy with training and could not drive the van. Previous interviews with the AD on 12/21/2023 and 07/12/2024 revealed the AD has had to drive the facility van in previous instances. The AD also noted that they have filled in for front desk staff as needed. Interview with the administrator at 3:15 p.m. today confirmed that the AD had to drive the facility van yesterday when the designated driver was absent. The administrator confirmed that the AD has had to fill the role of the facility driver when no driver was available. When the AD drove the facility van, they were not fulfilling their full-time responsibility as an Activity Director. Therefore, a deficiency is issued on the corresponding LIC 809-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.