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32 | Common areas and exteriors are clean, have space for activities. Some public areas have video only camera surviellance, LPA asked for the facility to add to the admission agreement an amendment document that notifies the resident they would be potentially video recorded. One balcony fence is out of repair, Maintenance Director was made aware of the fence and immediately put in a work order. evacuation route is a open parking lot, its accessible from most exits from the facility with cement sloped walkways of at least 36 inches.
MARs/Medication inspection had doses missing in the MARs for 3 clients for routine medication passes. One client was missing 1 medication on 2 days in a row. Explanation given to the LPA verbally was that the doses were forgotten to be recorded, explanation did not make it to the daily log. LPA noted medication doses were not forgotten to be logged with other medications dispersed at the same time. One client was missing multiple (3+) medications on 5pm and 8pm dispersals for the 30th of June. Explanation given to the LPA verbally was that other concerns going on with the client at the time(client refusing medications, hospice complication), explanation for the refusal made it to the log, record was not updated to reflect the status of the other medications dispersed or not dispersed. One clients MARs for the 8am morning dispersal was missing 7/1/26. LPA was given the verbal explanation that the log for this morning has yet to be filled out, LPA was checking the logs at 1pm, after the noon dispersal. LPA gave guidance to use the daily notes sections of the log invesigate issues with the dispersal log.
Signal system in use was tested, response time was 27 seconds.
First aid kit has all requred items. fire extinguishers are dated May/2026.
Administrator records were reviewed, required postings (ombudsman, federal workers rights, patient rights, evacuation route on facility sketch), liability insurance, infection control plan, evacuation plan, Administrator certificate, and facility license. Files are present and up-to-date,
9 Client files were reviewed, preapprisial, admission agreements, recent 602/603, health screening, and incident reports. files are present and up to date.
5 Staff files were reviewed. health screenings, first aid/cpr, background checks, and starting employee paperwork. files are present and up to date. Contining training, every month hour different topics, is kept seperately from the staff files.
4 staff and 1 administrator was interviewed. 4 clients were interviewed.
No citations issued, a copy of the report was read and given to the administrator. exit interview completed |