Follow-up on corrections·March 11, 2025

At 7:45am on 03/11/2025, Licensing Program Analysts (LPAs) Jeffries and Haner-Tomasko arrived to the facility unannounced to conduct a Case Management visit and a subsequent complaint on a separate report. LPAs met with Administrator, Edwin Ingan, announced who they are and the reason for the visit. As a result of the subsequent complaint investigation conducted on this visit, it was discovered that the facility has failed to repot any changes in conditions with Serious Incident Reports (SIR) of the residents or any Deaths Reports that have occurred or Hospice Notifications. LPA reviewed both the Serious Incident Report file, Death Reports, and Hospice Notifications (Efax for review for 405802274) and found zero SIR's, zero Death reports, and zero Hospice Notifications. LAP's reviewed Resident 1 (R1) Hospital visit discharge paper work dated 01/21/2025. This hospitalization was not reported to Community Care Licensing by the facility or Administrator. This is a failure to report to licensing and a citation for Reporting Requirements [87211(1)(a)] is issued from this report. Licensee stated that they have had deaths and hospice residence in the past 3 years at this facility. Administrator stated that he had faxed report to LPA Rankin. On 03/11/2025 LPA Jeffries confirmed by phone call that all reports Administrator submitted were filed, LPA Jeffries noted zero reports file for this facility. Report read, citation issued, appeal rights and report provided.