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 the reason for the visit.

Review of R2's and resident #5 (R5's) Physician's Reports revealed their ambulatory status as bedridden. Review of the facility sketch revealed only bedroom #3 can retain a bedridden resident. R5 is in bedroom labeled #3 according to the facility sketch. R2 in not in a bedroom cleared for bedridden.

Prohibited health condition for resident #3 (R3). R3, Licensee and wound care agency staff confirmed resident has a wound. According to the wound care agency staff it is a stage 4. LPA was not provided documentation or a care plan or exception letter requesting to retain resident. R1 may also have a wound. LPA requested Home Health documentation.

While conducting the physical plant tour LPA observed three (03), Resident #1 (R1), R2 and R5 have "full" bed rails. LPA observed the bed rails extended the entire length of the beds . According to Josephine only Resident #2 (R2) is receiving Hospice services.

While reviewing resident records LPA did not observed a Pre-Admission Appraisal for R1 and R2. R1 was missing a Physician's Report with tuberculosis ( TB) test results. According to Josephine the LIC602A form was provided to R1's doctor and the facility is waiting for it to be completed and returned.

Josephine provided an updated LC500 to LPA. Review of staff #1's (S1's) record revealed they do not have a health screening with TB results. According to Josephine S1 last worked on Monday, May 5th 2025.

During physical plant tour LPA passed by room labeled #1 and it had a urine odor coming from inside the bedroom. According to wound care agency staff they agreed the room smelled of urine.

At 4:30 p.m., LPA observed Licensee changing a resident's soild undergarments without gloves.

Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report provided.