Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 - year annual inspection. Administrator (ADM), Elaine Yalung was called and states she was unable to meet LPA at the facility. LPA met with Lead Caregiver, Evelyn Yalung.

During visit, LPA toured the facility with staff to include the living room, dining room, kitchen, resident bedrooms, staff bedroom, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. 3 staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 76 degrees Fahrenheit.

Facility currently has 4 hospice care residents. (The facility is pending approval for an increase of hospice care residents as of 10/09/2023). 3 residents under hospice care observed with bed rails that extends half the length of the bed. 2 residents did not have a physician's order for half rails in their records. During visit, the 2 resident's hospice care nurse arrived to the facility to drop off their hospice care notes from this morning. Nurse states the residents are provided a physician's order for a "hospital bed", but the physician's order does not specify "half rails". Hospice nurse placed an order for "half rails" and is pending a final signature from the physician. Facility will obtain the order once completed. 1 resident under hospice care observed with full-length bed rails. LPA did not locate the resident's hospice care plan in the facility. ADM emailed resident's hospice care plan to LPA, but LPA did not locate an order for full-length bed rails in the hospice care plan. ADM called the hospice nurse who later sent the physician's order for full-length bed rails signed and dated on 10/26/2023.