Follow-up on corrections·September 29, 2023

Licensing Program Analyst (LPA) Darius Williams conducted a visit to the facility. LPA Williams met with Administrator Mona and discussed the purpose of the visit. LPA Williams toured the facility and noticed Resident 1 lying in their bed with full bed rails (bed rails the entire length of the bed). LPA Williams reviewed their Hospice Care Plan, dated 8/29/2023, and only located mention of half bed rails. Administrator did not locate any mention of full bed rails in the Hospice Care Plan. Administrator reported she will contact R1's hospice agency and either change to half bed rails, as stated in the care plan, or specify the need for full bed rails. Plan of correction was reviewed and discussed with the Administrator. An exit interview was conducted and a copy of this report will be provided via e-mail.