Facility Evaluation Report

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10:45AM to conduct a non-compliance inspection. LPA followed up on the following areas which were initially addressed during a non-compliance meeting dated 07/21/2021. LPA met with Executive Director, Ric Pielstick.

Medications: Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file.

LPA observed medications to be double locked in medication room. LPA and Health Services Director (HSD) toured the Memory Care unit and conducted an inspection of 3 residents apartments. 3 of 3 apartments did not contain any unlocked medications.

Prohibited Conditions: Facility retained a resident with a prohibited condition.

LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 0 of 6 resident files reviewed contained evidence of a resident being retained with a prohibited health condition.

Timely Medical Attention: Facility failed to seek timely medical attention.

LPA reviewed incident reports and confirmed that facility has been seeking timely medical attention.

Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required.

LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 6 of 6 files had medical assessments completed as required per regulation.