Facility Evaluation Report

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to continue an annual inspection. LPA Met with Executive Director Jackie hernandez to explain the purpose of the visit.

On the previous visit, LPM reviewed 11 resident files of which 4/11 were hospice residents and 4/11 resided in the MC section of the community. During the file review the LPM reviewed associated incident reports ensuring the RP and MD were notified, medication orders were addressed and if a change of condition occurred an updated care plan was developed. 2 residents had a change of condition which would have triggered an updated reappraisal. tDuring the inspection, the weight logs, service notes and ADL charting were not reviewed. LPA has returned today to address any concerns related to these.

Pullcord log from the last three weeks were reviwed, common reason is toilet/bathing, common response time is 20 seconds to 4 minutes, a few outlier times are 9-13 minutes.

Weight logs are completed for residents with relevant issues to sudden changes in weight. no concerns.

Service notes/ADL charting describes in detail the Bowel Movement, bathing, incontinence care, grooming, and shower habits appropriately to the concern of the residents. Logs have created by dates and authors consistant with daily use of the log. no concerns excepting R4 med error morphine double dose 02162026.

Citations were issued. a copy of the report was read and given to the executive director. appeal rights were provided, exit interview was conducted.