Facility Evaluation Report

Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned that there are related deficiencies observed during the visit. LPA met with Blaine Lyons - Acting Executive Director. Following item were observed during investigation visits:

Department has learned after alarm records review that facility alarm system on 2/17/2022 show that from 100 % of calls 22 % were answered in a time frame of 10 to 29 min and 9.6 % of calls took 30 min to 1 hr 18 min to be answered. Facility on 2/17/2022 had according to records provided by facility 102 Assisted Living residents'. Acting Executive Director email stated that facility had 1 medication technician and 3 agency care staff. However, facility records show that there were only 3 staff on NOC shift counting medication technician and after 4 AM only one staff on shift. (copy of records on file) Records show that call bell alarms in Assisted Living were not answered in a timely matter to ensure that residents' needs were meet. (see LIC 809-D)

During visit to facility on 8/1/2022 Department reviewed residents' and staff files and learned that 4 out of 4 residents' files have no updated care plan as required by Title 22 Regulations. Residents R1 & R2 have a diagnosis of dementia and care plans dated 7/25 and 3/16/2021 while residents R3 no care plan found – only has a pre-assessment which dates 10/12/2020 & R4 has a care plan in progress that dated 11/9/2018. In addition, resident R4 has a physical assessment (LIC 602) dated 3/31/2021 however; it is not signed. (see LIC 809-D)