Follow-up·April 28, 2023

On 4/28/23 at approximately 3:15pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management in order to follow up on action items identified during the legal/non-compliance conference held on 4/12/23. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit. The following updates were obtained: Licensees stated they will do the following to achieve continued and substantial compliance (updates are in BOLD text): · Immediately identify 2 medical transports companies in the area to provide non-emergency transport- AMR and CMS were contacted, they advised no contract is needed and that services can be requested as needed · Immediately ensure Administrator presence for a minimum of 40 hours a week- Stephenie Siewe will submit Administrators certification application no later than Monday May 1, 2023 and until then Licensee is at facility 40 hours a week and has a current certification. · Immediately refrain from accepting or retaining residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia- Immediately complied with · The licensee will evaluate the current STD850 to ensure that they are in compliance with the state Fire Marshall; The facility has a non ambulatory fire clearance for each room that will be used to accommodate a resident with dementia within 2 days; submit an updated LIC200 and facility sketch.- Email sent to LPA Jensen within the required time frame. Continued on LIC 809C.... · Submit a new LIC 500 by 04/17/23 · Submit an Activity Calendar within 2 days · In 7 days comply with all regulations specific to facilities licensed for a capacity of 16 or greater OR seek a decrease in capacity · Conduct a self assessment of all resident and personal files within 30 days and make needed updates per requirements. · Have all food preparation staff ServSafe certified within 30 days. · Utilize an off site training for Mandated Reporting and de-escalation within 30 days · Engage the residents in the menu process within 30 days and document preferences. · Assess and replace mattresses and/or waterproof mattress sleeves within 90 days. · Review and Amend the current incontinence plan to be approved by the Department within 90 days.