Facility Evaluation Report

At approximately 1:15PM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to continue a Required 1 Year Visit and met with the front desk receptionist. Executive Director, Jessica Graham arrived during visit at approximately 2:00PM. Facility is a Residential Care Facility for the Elderly that provides care and assistance for Older Adults in Assisted Living and Memory Care. Facility has an approved fire clearance for 81 Non-Ambulatory Residents, and 14 Bedridden Residents for a total capacity of 95 Residents. Facility has a Hospice Waiver for 10 individuals. Upon arrival, LPAs were informed that there were 41 Residents in care. LPAs were also informed there were 48 staff members on site.

LPAs reviewed a sample size of 6 resident files. Files were found to be well organized, thorough and contained the required documentation. LPAs also reviewed a sample size of 2 medication records.

LPAs also followed up on self-reported incidents that were submitted to Community Care Licensing (CCL).

The following incident reports were discussed with Executive Director:

Incident Report 1/Incident Report 2: CCL received an incident report on 06/19/2023. The report states that on 06/08/2023, Resident 1 (R1) was being transferred by two staff members. During the transfer, R1's wheelchair became unlocked resulting in R1 being assisted to the ground by staff. R1 was observed to bump their head on the wall but refused to be evaluated by Emergency Personnel. Report stated that R1's Responsible Party was to provide a new wheelchair for R1. Facility contacted R1's physician and responsible party appropriately. On 06/19/2023, CCL received updated incident report for R1. Report states that on 06/9/2023, R1 was being transferred by two staff members. R1's wheelchair became unlocked resulting in R1 being assisted to the ground by staff. Facility contacted R1's physician and responsible party appropriately. Report stated that R1 would use Facility's wheelchair until Responsible Party provided one.

LPAs discussed R1 with Executive Director. Per conversation with Executive Director, R1 refused to have their wheelchair replaced. Facility replaced wheelchair the next day with a brand new one when it was observed that the wheelchair was in disrepair.