Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility. During the LPA's investigation deficiencies were found and are documented in this report. LPA met with Administrator, Vicki Estelle who was informed of the purpose of the visit.

LPA reviewed the file for Resident #1 (R1) and found the following:

It was also found that R1 had been taking medication #2 (M1) and had an order from hospital to hold the medication 8/20/2020. Upon review of the MARS log it was found that M1 had been initialed as given from 8/20 to 8/31/2020. LPA interview staff who stated typically residents give the facility discharge paper work and make a notation on the MARS log and stated the facility must not have received the order to stop the medication. Therefore, the facility failed to hold M1 from R1.

LPA conducted interviews and records review and found that on 8/13/2020 R1 was admitted to hospital. The diagnosis was found to be that R1 had overdosed on medication #3 (M2) which had contributed to R1's condition (C1) and lead to intoxication. R1 had a history of overdose which was documented in the facility care plan. R1's care plan stated R1 was classified as "independent". LPA interviewed staff who stated that they were unaware of how R1 was over medicated, and stated they may have gotten it else where as R1 had unsupervised outings in the community. M2 is not a controlled substance. Staff stated they were unaware if the resident's care plan was updated after the incident. Therefore, it was found that there was a lacked of care and supervision from the facility which lead to resident intoxication.

The deficiencies were documented on an LIC809-D page where plans of correction were discussed and created with... An exit interview was conducted where this report, LIC809-D pages, as well as appeal rights were reviewed and provided to Administrator, Vicki Estelle.