Facility Evaluation Report

This case management visit conducted by Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan visit due to complaint volume, issues observed during previous licensing visits to include but not limited to insufficient staffing to provide care and supervision. Upon arrival, licensing representatives observed the following:

Residents unable to open door to go to break area

Strong urine odor in elevator/and third floor hallways, common areas

One caregiver is on duty to provide care and supervision for 9 residents requiring extensive care 3 residents observed in wheelchairs, requiring escort assistance, left without supervision.

*There were non-ambulatory clients on the 3rd floor, and it was not clear how the staff would assist them during emergencies. Emergency plan of operation was reviewed and required updates.

At least one (1) or more residents require a 2 person assist in transferring in/out of bed/chair

At least one (1) or more resident assessments have conflicting information regarding level of care needed

(Bathing/independent/toileting/dressing) compared to medical assessments

At least one (1) or more resident documents do not have Administrators/Directors signature/date

(Resident Appraisals/Needs and Services plans)

Due to time constraints deficiencies will be addressed during a later visit.

Exit interview conducted/copy of report given