Follow-up·April 11, 2024

On 04-11-2024 at 8:45 AM, Licensing Program Analysts (LPAs) Avelina Martinez and Renee Campbell conducted an unannounced visit to conduct a case management. LPA Avelina Martinez and LPA Renee Campbell met with Georgia Wilcomb and explained the purpose of today's visit. The purpose of this visit is follow up on learned deficiencies during a complaint investigation 27-AS-20240125090756. On April 04, 2024, LPA Martinez conducted an unannounced complaint visit. During April 04, 2024 complaint visit, LPA Martinez witnessed no care staff at approximately 8:30 AM. It was learned the assigned volunteer care staff left the facility for unknown time frame. LPA Martinez called the Licensee upon arrival at facility, and resident 1 (R1) called volunteer staff 1 (VS1). VS1 arrived at the facility at approximately 9:00 AM. VS1 left the facility to complete personal errands. As a result, the facility will be cited for not providing care and supervision to residents in care. An civil penalty shall be assessed on April 11, 2024 in the amount of $ 500.00 for the immediate health and safety risk of leaving residents alone. Additionally, LPA Martinez was informed R1 assists resident 2 (R2) with showers. Georgia Welcomb was informed only care staff should be providing care and supervision to residents in care. Furthermore, Georgia was advised R1 is not able to oversee the facility and residents in care due to the fact that R1 is a resident. LPA Martinez also reviewed the September 09, 2023 Non-Compliance Conference compliance (NCC) agreement and concerns. Due to recent care and supervision deficiency, the facility has not complied with NCC compliance agreement. The continued concerns are the following: Facility staffing Oversight of facility staff for proper care and supervision Due to immediate health and safety concerns and history of non-compliance with staffing regulations, LPA Martinez requested weekly work schedules be emailed every Monday at 8:00 starting April 15, 2024 until additional staffing has been hired. Staffing Plan: Licensee reported they are present at the facility 40 hours per week. The Licensee has finger printed/background clearance 4 potential employees. Licensee will add VS1 on payroll, and have a set schedule. LPA Martinez will continue to follow up with Georgia regarding staffing concerns. As a result, of this case management, deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of this report, 809-D page, and appeals rights were provided to the facility.