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25 | LPA Shawna Doucette and Kamaldeep Kaur arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Staff Sue Devilbiss. LPA explained the purpose of the visit and met with Regional Director Steven Cruz and Staff Ty Scherer.
A tour of the facility was conducted with Staff Ty Scherer. The facility was set at 75 F temperature and free of passageway obstructions inside and outside.
Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication cart in office/medication room. Cleaning supplies were in a locked storage closet. Smoke detectors and carbon monoxide detectors were checked and operating. Facility had a pull station fire alarm. Facility has a fire sprinkler system. Fire extinguishers were charged and had service dates of 05/13/24. LPA checked water temperature in resident bathroom which was 117.5 F. Resident bathroom had a rusted bathtub and rusted sink. The other resident bathroom had black mold and the flooring is damaged. LPA took photos.
There was outdoor seating for the residents.
Resident, medication and staff records were reviewed. While reviewing records, LPA observed R2 receiving morning medication at noon and R4 not receiving medication on 7/14/24, 07/15/24 and 07/16/24. Facility crossed out original label stating to administer in the morning with a black marker and wrote in 12 PM. Facility did not have doctor orders for R1's restricted health care plan, showing when blood sugar tests should be completed and a doctor order for sliding scale as to how much medication is to be administered depending on blood sugar test. LPA took photos of medication errors. R1 did not have a needs and service plan. Training has dates and hours with names of staff but does not state the source of where the training.
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