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25 | Licensing Program Analysts (LPA) Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct an annual inspection. LPA's explained the purpose of the visit and met with Administrator Linda Poythress.
LPAs entered the memory care portion of the facility which was odor and clutter free. Facility is licensed for a capacity of 82 with a current census of 73. Facility has shared and private rooms for residents.
LPA's reviewed a sample of resident files, infection control plan, and disaster plan. Facility has 2 resident that are regional center clients. Facility does not have IPP's for R1 and R2. While reviewing R3's records, it was found an incident occurred on 9/19/24 and was not reported to the Dept. LPA's reviewed Admissions Agreements for SSI resident. Hospice records were reviewed and R7's residents records were found with R8's records. R3's and R9's admissions agreements do not match rate increase letter. Facility does not have Hospice Care plans for residents on Hospice.
Facility has an activities room, where residents are provided activities. LPA B. Miranda attempted to interview 2 residents. One resident was not available. R3 was interviewed regarding injectable medication, R3 stated they inject their own medication and prick their own finger to check sugar levels. While walking to the resident's rooms to interview LPA B. Miranda observed a doorway outside of the dining area to be in need of repair. LPA also observed a window in the hallway to the dining area to be cracked.
Annual inspection was not completed at this time. LPAs will return at a later time to complete annual inspection. Deficiencies will be cited at follow-up visit. LPA's were not able to obtain requested documents during the visit.
Exit interview was conducted and a copy of this report LIC809 was provided to Administrator Linda Poythress. |