Facility Evaluation Report

Licensing Program Analysts (LPA) Avelina Martinez and LPA Arielle Pascua arrived at facility unannounced to conduct a case management visit on 06/13/2022. LPA Martinez and LPA Arielle Pascua met with Kirk Goodin and explained the purpose of the visit.

The purpose of the visit today, is in response to learned deficiencies during a complaint investigation. Resident 1 (R1) had various significant physical, medical, and mental changes while residing at this facility. The facility staff documented R1's condition changes on daily nurse's notes and via physician fax communication sheet. However, a reassessment after each significant health change was not being completed. LPA Martinez obtained two different forms of R1's health assessments. One assessment was dated January 19, 2022 and the other was date April 10, 2022.

Beginning on February 9, 2022, it was noted R1 was having suicidal ideations and continued on February 12,2022. Moreover, monitoring of R1 occurred on the following dates: February 12, 2022; February 13, 2022; February 17, 2022; February 18, 2022; February 19, 2022; and the last monitoring entry was on February 20, 2022.

Furthermore, facility staff informed R1's physician of the suicidal ideations via fax communication on February 22, 2022 and requested an order for Seroquel. There are no other notes that indicate R1's responsible party was informed of the suicidal ideations. There was no other documentation noting the facility staff continued to monitor R1's suicidal ideations. Additionally, the facility did not complete a new assessment after R1's suicidal ideations incidents.