Facility Evaluation Report

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20250429144827. LPA met with the Licensee and explained t he reason for the visit. LPA may also be citing citations that have not been corrected by Licensee and those citations LPA failed to conduct a follow-up visit, within 10 business days after the POC due date.

Previously cited on case management visit 05/07/2025.

While conducting the physical plant tour today LPA observed "full" bed rails on resident #1's (R1's) bed. LPA observed the bed rails extended the entire length of the bed.

Review of R1's and resident #2 (R2's) Physician's Reports revealed their ambulatory status as bedridden. Review of the facility sketch revealed only bedroom #3 can retain a bedridden resident. R2 is in bedroom labeled #3 according to the facility sketch. R1 in not in a bedroom cleared for bedridden. According to the Licensee R1 is able to be placed on a wheel chair with the use of a hoyer lift. According to Licensee the bedridden status is temporary and they are working with physical therapy to change status. According to R1's physician's report (LIC602A) the status is expected to persist 365 days or maybe permanent. According to the licensee they believe the LIC602A for R1 is incorrect and will request R1's family to get an update and accurate physician's report.