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- Licensing Specialist: Michele Sutton.
- Several reports of self-harm incidents from 01/26/23 – 01/27/23 were received on 01/31/23. Facility did not receive copy of signed CAA until 01/30/23, and the ADON only recently (01/27/23) became responsible for reporting incidents. Moving forward, the facility will be cited for any incidents that are not reported within 1 business day of occurrence, and facility will be cited for any incidents that are not reported within the timeframes specified in the Corrective Action Agreement.
- TA –
- 109.1.f – Late reporting (6 incidents).
