Facility Evaluation Report

*** Amended… On 4/6/2023 during case management inspection at this facility, LPA Cuadra issued in error the wrong citation #80075 (b) due to facility failed to administer medication per physician’s orders. LPA cited the facility under General Regulations instead of citing under Residential Care Facilities for the Elderly (RCFE) regulations. LPA Leibert will amend case management LIC809 and LIC809D reports and will be issuing the citation under RCFE Regulations. Also, civil penalties issued on 4/6/2023 was dismissed.

On 4/6/2023 Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and met with Executive Director/Administrator Ric Pielstick. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 7/2/21:

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. At the time of inspection Medications were stored and locked at all times. However, on 3/4/2023, CCL received a self-incident report notifying CCL that there was a medication error which occurred on 3/4/23 involving resident (R1) resulting in staff (S1) have received re-training on 3/5/2023 to prevent this type of incident from happening again. S1 recognized the error and contacted the physician and family. LPA was provided with S1 re-training records.

Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's care notes to document daily resident's care notes.

Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident report logs received within 7 days as indicated per regulation.

Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed 6 resident (R1, R2, R3, R4, R5) medical records including their Physician’s reports (LIC602) which were found within compliance.

Facility Food Services: Facility kitchen area was toured by LPA/Memory Care Director and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation.