Facility Evaluation Report

On 5/17/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on incident reports and a general health & safety check and was greeted by acting Administrator, Wendi Counta (AA). The facility submitted two incident reports involving staff medication errors. No side effects were observed from either client and AA appropriately contacted client medical providers for support. AA provided additional training for staff for corrective actions along with developing plans to address specific areas of concern within the medication room and medication record keeping. LPA and AA discussed plans to provide clients with education on medication along with more efficient strategies for staff to organize medication records and administration. AA is currently developing protocols for kitchen staff safety, in plans of implementing a client engaged cooking program, allowing clients to develop skills and create food menu based on preferences.

LPA and AA also briefly discussed plans for increased activities and updating the facility signal system. LPA finds that AA is implementing a plan of action to clearly addresses the areas of concern in recent incidents reported in a timely and appropriate manner.

No deficiencies cited during today's visit.