Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue a deficiency observed during the investigation for complaint #28-AS-20241206090302. LPA met with Administrator, Marsha Murray, and explained the reason for the visit.

During the complaint investigation, LPA discovered that staff training was not completed annually for those who have a restricted health condition. The restricted health condition plan was outdated, and staff lacked current training on diabetes. Staff interviewed acknowledge there was no registered nurse for most of the year in 2024 to provide training to staff and oversee medication. Staff did not follow the physician’s order of calling the doctor when the client’s blood sugar level went above 250 consistently, nor attempted to obtain clarification of the term “consistently”. Due to staff not receiving training on diabetes and the importance of following the physician’s order, Client #1’s serious complications could have been prevented.

A deficiency has been issued on the LIC809D form. An exit interview was held, and a copy of this report, along with appeal rights, was given to M. Murray.