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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a quarterly on-site case management inspection pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022. LPA met with Andrea Armstrong, Administrator (by phone) and Kylie Whitaker, Health Services Director (HSD) and explained purpose of inspection. The last quarterly inspection was conducted on 5/10/23.
During today's inspection, LPA reviewed the "Compliance Binder" and observed it to be organized and to contain tab dividers for each requirement as set forth in in the Stipulation. LPA observed current documentation for the following requirements:
- Quarterly Medication Audit - training conducted by an outside Pharmacy RN, on 6/8/23 and scheduled for 7/27/23. There have been no errors found during the audits.
- High risk residents- LPA observed weekly notes written by HSD based on weekly meeting with facility nurses and Med-Techs every Wednesday. Residents with recent concerns are discussed.
- Weekly door checks for alarms and obstruction of door exits. LPA observed documentation on each log to be for the last 2 months to have been initialed as completed. HSD will email documentation for July to LPA once obtained from the Maintenance Director- by 7/27/23.
- Monthly elopement drills- Elopement drills are now being conducted on a weekly basis. Last drill conducted on 7/26/23 . Monthly fire drills were conducted in May and June.
- June training- scheduled every Thursday. LPA reviewed training documentation for 7/6- topic was Elopment Drill (1 hour); 7/13- Dementia Tour (2 hours) ; 7/20- skin problems with elderly (1 hour); 7/27- last hour scheduled for Med-Techs.
During today's inspection, LPA also conducted a health and safety tour of the inside of the facility and did not observe any health and safety risk or personal rights violation.. LPA observed many residents to be in the activity room watching a movie.
There are no citations issued on this report. The next quarterly inspection to be conducted on/around October/November 2023. Exit interview. Copy of report provided to Health and Services Director.
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