Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with staff, Onejeh Jones and Jackie Cole-Cochrane. LPA stated the reason for the inspection was to follow up on (2) incident reports recently submitted to the Department. LPA discussed the incident reports (2) with the Administrator, by phone. All residents were napping in their rooms.

On May 26, 2026, the administrator received a phone call from the day program that resident (R1) reported that facility staff had taken their cigarettes. Staff Jones stated she found the alleged missing cigarettes (1 pack) under (R1's) pillow. The administrator stated (R1) short-term memory loss and is confused/disoriented some of the time, and (R1) has a habit of misplacing items often. The administrator stated the new issue with (R1) is a friend gives (R1) more cigarettes while they are attending day program, but doesn't give them to the staff when returning to the care home. (R1) is aware of the house rules now and will allow staff to safeguard, with a lighter, and ask for them, when desired. Staff Jones showed LPA a large ziploc bag where multiple packs of cigarettes and a lighter are securely stored.

On May 26, 2026, resident (R2) received a full shower after the hospice nurse provided clearance. (R2) received bed baths due to transfer concerns related to a very swollen ankle when moving in in April 2026. After this bath, (R2) tried to get up multiple times, but staff told her to call for assistance. (R2) was able to slide to the end of the bed and sustain a skin tear and sore back while slipping out of bed. Hospice staff was notified and arrived to provide first aid/skin tear care. Staff Jones stated the hospice nurse was last here Wednesday, this week, and changed the dressing. LPA observed bed pads covering full bed rails on (R2's) bed. LPA also observed (R2) to be resting comfortably and wearing clean dressing on their left forearm. The administrator and staff continually remind (R2) to use their call button, and staff regularly check on (R2), leaving the door open. It appears the facility took appropriate and timely action in both incidents. There are no deficiencies issued in this report. Exit interview with Staff Jones. Copy of report provided.