Facility Evaluation Report

LPA Johnson arrived and met with the Regional Director, who assisted LPA with the visit. The purpose of this visit was to follow up on the citations given and amend the deficiency from an "A" to a "B" to reflect the non-immediate safety risk to R1.

The appeal to the Department questioned that the failure to follow a proper medication order for R1 did not pose an immediate health and safety risk to R1 and a Type "A" deficiency was not warranted. The facilities presented that R1 never had any adverse medical outcome due to the error and therefore the "A" citation was not warranted and should be a "B" citation instead.

LPA reviewed records and medications charting for R1. To confirm that the medication are present and being given according to the doctors orders.

LPA Johnson and Mary were walking to the medication room to get the medication administration record for R1, LPA and Mary observed and confirmed that the housekeeping cart was absent of the housekeeper or unmanned in the main hallway with unlocked toxins accessible to the residents (Zeps wall cleaner and other unmarked cleaning items.) Mary was able to locate the housekeeper and informed her that the cart should be locked at all times when she is not present. The housekeeper locked the cart.

As a result of this visit deficiencies were observed and cited on the attached 809D page. LPA provided the facility with a report to amend the citation and appeal rights for the citation today.