Facility Evaluation Report

On 8/2/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220609140245. LPA met with the administrator and explained the purpose of the visit.

During the course of the investigation, the allegation of staff leave residents unattended for extended period of time was deemed to be unsubstantiated. However, Staff #2 reported sleeping on the couch in the resident's living.

Based on the complaint investigation, the facility did not ensure to provide a comfortable living accommodations and privacy for residents and staff. This deficiency will be cited on LIC809D.

During the course of the investigation, the allegation of staff did not provide residents with walker was deemed unfounded. However, LPA observed resident #1 (R1)'s bed has two quarter bed rails installed by head of the bed and R1 reported facility staff placed another removable metal device by the foot of the bed and a dresser in middle space between the head and the foot of the bed.

Facility staff acknowledged the above devices were placed next to R1's bed and reported the intent was to prevent R1 from falling out of the bed.

According to the documents provided, there was no physician's order for any of the devices used above and administrator acknowledged that R1 used the quarter bed rails for reposition while in bed. However, there was no physician's order.