Follow-up·November 14, 2022

On 11/14/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management visit. LPA was greeted and granted entry by Darlene Lindley, administrator, and explained the purpose of the visit. The purpose of the visit was the delivery of an amended version of the Complaint Investigation Report initially delivered to the facility on 10/28/2022. Amendments were performed upon Community Care Licensing management request to clarify allegation #1 in regard to the regulations being applied as well as to remove items that were to be integrated into a distinct case management report as they were unrelated to the initial allegations. In addition to this, LPA requested and obtained documentation of the association status of staff members S1 and S2. Staff members had been observed to not yet be associated with the facility on 10/28/2022. Both staff members are now shown to be correctly associated. All other individuals on roster are correctly cleared and associated on the day of this visit. Hospice admission agreement for resident R1 was also provided by the facility. Document had been observed to be missing from R1's file on 10/28/2022. File is now updated and complete. The admission agreement for resident R2 was not yet signed during the 10/28/2022 visit. A copy of the signed agreement was provided by administrator during the present visit. Exit interview was conducted with facility representative and a copy of this report along with a copy of the amended report were provided and left at the facility.