Follow-up·June 30, 2025

Licensing Program Analyst (LPA) Albert Johnson arrived at the facility unannounced to complete a health, safety, and welfare visit of the clients in care. LPA met with Staff and explained the reason for the inspection. LPA reviewed 5 incident reports received 2 out of 5 incident reports were reported late. LPA also reviewed facility’s fall prevention program and conducted interviews with the nurse and Administrator. LPA also conducted a review of discharge plans for the 5 residents and observed that the facility has made arrangements for the review of the service plans with responsible parties for those residents returning. Additionally during review of incident report, it was determined that 2 of 14 incident reports were submitted to regional office beyond seven days of occurrence and not within reporting requirement regulations. As a result of today’s visit, advisories were given. .