Present at today’s meeting were the following: Kristin Heffernan Licensing Program Manager (LPM), Kelly Dulek Licensing Program Analyst (LPA), Dr. Rashita Aggarwal Licensee Representative/Administrator, and Manju Natarajan Assistant Administrator.

As this facility has only been licensed for 1 (one) year following a Change of Ownership, LPM discussed the Department’s Administrative Action process.

Concerns were in the area of medication administration and physical plant issues: pests, both alive and deceased were observed in the kitchen area, items blocking the facility’s passageways, and hot water temperature. LPA also observed knives and other sharps, as well as cleaning supplies accessible to residents.

The purpose of today’s visit was to discuss concerns related to a citation issued for bed rails. During the visit, LPA observed the Facility Designee, who is not a medical professional, writing in orders for half bed rails for a resident on the resident’s existing physician’s report that had been previously signed by the resident’s doctor. Licensee acknowledged the Facility Designee was not authorized to do so. During today’s visit, Licensee stated that the facility will no longer be using the physican’s report to document orders for bed rails. The Licensee will be utilizing a separate form for both the resident’s family and the physician to acknowledge a resident’s need for bed rails. Licensee stated that the Facility Designee is currently still employed but has been retrained and will have limited hours working at the facility going forward.

It was also discussed that currently Rashita Aggarwal is Administrator of record at 6 (six) licensed facilities, however the Department advises that an individual be designated as Administrator at a maximum of 2 (two) Report Continued on LIC 809-C

Exit interview conducted. Signatures obtained. A copy of today’s report was provided.