Facility Evaluation Report

Licensing Program Analysts (LPAs) Cuadra and Rummonds arrived at the facility to conduct an unannounced case management Legal/ Non-compliance inspection and cite deficiencies discovered during a complaint investigation met with Executive Director/acting Administrator Liza Hix. 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. During facility tour, LPAs/Executive Director observed staff (S1) crushing medications for residents in care. LPAs were informed that there are physician's crush orders on file to crush medications for some residents (R1, R2, R3, R4, R5 & R6). However, there is no crush order from a physician in R1 & R4's file. Administrator requested LPAs time to locate crush orders and email them to for review. Administrator agreed that failure to provide physician's crush order to CCL will result in a citation. LPAs need to conduct further investigation and review prior to make a final determination.

Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's care notes to document daily resident's care notes and they are not maintained current month of October 2023. LPAs/Executive Director discussed the importance of documenting resident's care notes timely.

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 & R6) medical records including their Physician’s reports (LIC602) had been updated within 12 months as indicated per regulation.

Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident report logs received and residents have been assisted with timely medical attention as indicated per regulation. Continued on LIC809C...