Inspection Report
Biennial Survey
Census: 42
Capacity: 48
Deficiencies: 1
Jul 13, 2023
Visit Reason
The visit was a biennial survey to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs for a Level IV PNMI Residential Care Facility.
Findings
The facility was found not in substantial compliance due to failure to develop and implement a service plan within 30 calendar days of admission for one of three resident records reviewed.
Deficiencies (1)
| Description |
|---|
| One of three resident records did not contain a service plan developed within 30 days of admission (Resident #2). |
Report Facts
Resident records reviewed: 3
Residents with deficient service plan: 1
Census: 42
Total capacity: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheldon Clyde Brett | Administrator | Named in relation to confirmation of findings at exit conference |
| Residential Care Director | Confirmed findings during survey and exit conference |
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