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- Licensing Specialist: Michele Sutton.
- Unannounced licensing visit completed. Licensing verified safety plan precautions were documented and observed for multiple residents, reviewed staffing sheet documentation, spoke to CEO regarding resident, and observed comfort room area. Licensing viewed camera footage for 2 self-harm incidents, with no concerns noted. Per CAA agreement, Licensing viewed environment of care maintenance logs (no concerns noted) and requested the new HR director attend the unit regulatory check training on 04/26/23. Licensing also followed up on a report from DSPQA IOC team that mail with confidential information was left outside unsecured at their time of visit; CEO reported she is in contact with USPS to explore options for securing mail, and Licensing requested this be completed by 03/31/23.
- Regs out of compliance –
- 912.4 – Box that toilet is in (bathroom 301) has trash, debris, and space for contraband on either side of the toilet. Facility plan is to place foam in the area, let it protrude, then cut/seal it (Complete by 03/15/23).
