Facility Evaluation Report

Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management-Deficiencies visit at the facility today, due to deficiencies observed during the investigation of complaint control # 29-AS-20210923141341. Upon entry the LPA was greeted by staff, as the Administrator advised the LPA they were not able to be present during today’s visit.

At 9:15 a.m., the LPA observed Staff #1 (S1), and Staff #2 (S2) not wearing face coverings/ masks. The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

At 9:26 a.m., during the physical plant tour, the LPA observed the facility’s kitchen refrigerator containing unsecured medication accessible to residents in care. At 9:27 a.m., the LPA advised the administrator via telephone medication shall be stored inaccessible to residents with dementia in a secured ‘Lock Box.’ The Administrator acknowledged, and stated a lock box will be purchased today 06/22/22.

At 9:29 a.m., during the physical plant tour, the LPA observed two (2) cabinets located under the facility kitchen sink in disrepairs; which contained accessible cleaning supplies to the residents in care. The LPA advised the Administrator of the cabinets not shutting properly.