Follow-up on corrections·October 15, 2021

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting a follow-up visit regarding complaint (#18-AS-20210126093050). LPA Colvin met with Caregiver Shirley DIgma and advised them of the purpose of the visit. During LPA Colvin's visit, LPA Colvin addressed the following issue which was discovered during the investigation: Through LPA Colvin's investigation of the complaint (#18-AS-20210126093050), LPA Colvin observed that one resident (R1) had been admitted to the hospital at least twice in 2020 (11/5/20 for 8 days and 12/5/20 for 7 days). Community Care Licensing (CCL) never received an Incident Report from the facility regarding these hospitalizations. In fact, CCL did not receive any Incident Reports or Death Reports from the facility for a period of over two years (8/7/18 to 1/5/21). All unusual incidents which may pose a risk to a resident's health or safety (such as: calls to 911 or medical emergencies) are to be reported to CCL within 7 calendar days. Deficiency cited. LPA Colvin conducted an exit interview with Caregiver Shirley Digma, and a copy of this report, LIC809D, and appeal rights were provided.