Facility Evaluation Report

7/16/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post licensing inspection. LPA met with Caregivers, and explained the purpose of the visit. Administrator then arrived shortly after tour was conducted.

Today's census is four residents with one resident on hospice services, facility is licensed for six non-ambulatory, hospice waiver of six.

LPA conducted a tour of the interior of the facility. Areas toured included but not limited to: kitchen, bathroom, residents bedrooms and the common areas. LPA observed four residents in care with two caregivers. LPA observed medications and sharps to be locked and inaccessible to residents in care.

LPA informed Administrator that all staff are to have the required initial and annual training as per §1569.625 Staff training; legislative findings; contents. LPA and Administrator discussed first aid training for all staff and at least one staff per shift with cardiopulmonary resuscitation (CPR) certification. LPA and Administrator discussed that all residents file are to have physician orders for each medication. LPA and Administrator discussed keeping communications and charting notes with hospice/home health agencies regarding residents condition.

File review conducted for residents and staff. At this time, no deficiencies cited.

Exit interview conducted and a copy of the report was provided.