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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 Kylie Whitaker, Administrator, and Julia Wihl, Business Office Manager and stated the reason for today's inspection.
LPA, Administrator and Business Office Manager reviewed the "Compliance Binder", where all documentation related to the stipulation requirements is filed.
- Weekly staffing schedules for months July- October, 2024 showing staffing coverage.
- Quarterly Medication Audit - training conducted by an outside Pharmacy RN, on 9/5/24; RN consultant did a MAR audit and facility health check on 10/31/24. Training on 8/29/24 and on Facilty Health Check and Med Pass Observation on 7/24/24.
- High risk residents- LPA observed weekly notes filed, thru 10/5/24, written by HSD based on weekly meeting with facility nurses and Med-Techs every Wednesday.
- Weekly door checks for alarms and obstruction of door exits. LPA observed documentation on each log by Maintenance Director, Administrator. Additional staff check to ensure egress alarms are working.
- Weekly to monthly elopement drills were completed July- October, 2024. October drill was conducted during the NOC shift. Stipulation only requires monthly drills be conducted. LPA reviewed documentation on file. For November 2024. (3) training will be conducted to total (4) hours due to the holiday.
- July- October 2024 training documentation for scheduled training every week. LPA observed a variety of topics including: Covid, Infection Control, Dementia, Hospice, skin issues, Dysphagia, Drug Diversion.
- Administrator stated the community has (2) water stations on site and staff will check on residents every 15 minutes on days with excessive heat outside.
LPA 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 enjoying activities in the activity room and others to be napping in their rooms.
There are no citations issued on this report. The next quarterly inspection to be conducted in February, 2025. Exit interview. Copy of report provided to Administrator. |