Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit for the purpose of inspecting facility for adequate staffing. At the time of inspection, LPA found 2 care staff and 1 med tech caring for 20 residents in the Memory Care (MC) unit and 3 care staff and 1 med tech in Assisted Living (AL), caring for 45 residents.

The facility was clean and orderly. Staff were engaged in providing care. LPA inspected several rooms in AL and found them to be clean with appropriate linens and residents clean and dressed appropriately. During the inspection, an incident was reported to LPA by resident (R1).

According to (R1) interview, a medication technician ( S1) attempted to give (R1) the wrong medication . Per R1, on 09/17/2024 S1 failed to review the identity of the resident or physician's orders for medications and placed the wrong medication in front of R1. R1 indicated that the medication was incorrect and after some discussion S1 removed the medication. In addtion, review of Medication Administration Record ( MAR) for residents (R2) and (R3) indicate medications were not dispensed as ordered on 9/17/24 for R2 and 9/18/24 and 9/19/24 for R2 and R3. (See LIC 809-D)

During the inspection of residents' rooms in memory care, LPA observed on two occasions (9/15/24 and 9/20/24) furniture was being used as a restraint to prevent residents from getting out of their beds. In one instance, R4 had a wheelchair pushed against the bed. (Photos taken)