Correction check·May 21, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction visit to follow up on deficiencies noted during annual visit conducted on 4/16/24 and 4/18/24. LPA met with Hongwei He and explained the reason for the visit. The following deficiencies were noted during the visit of 4/16/24 and 4/18/24: Type A - 87615(a)(2) Prohibited Health Conditions - On 4/18/24 During file review LPA observed that resident #1_#3(R1 - R3) have a prohibited health conditions. On 4/25/24 licensee did not provide a physician's report, order, or letter to clarify R1-R3 prohibited health condition. R1 -R3 were observed at the facility at the time of the visit. Deficiency was not cleared. On 5/7/24 LPA observed R1-R3 at the facility, reviewed physician's letter for R2 which notes R2 is no longer under a prohibited health condition. However, R1 and R3 continue to have a prohibited condition and reside at the facility. On 5/16/24 Administrator submitted an exception letter request for a prohibited health condition to the department. Deficiency cleared as of 5/21/24. Type A - 87608(a)(3) Postural Support - On 4/16/24 LPA observed 6 out of 6 residents have bed rails in their beds. On 4/18/24 during file review LPA observed there were no physician's bed rail request on file. On 4/25/24 LPA reviewed a physician's order for Resident #1(R1) which notes full bed rails however R1 is not on hospice. Physician' order for Resident #5 (R5) does not identify the type of rails that R5 may use. No other bed rails request were obtained. On 4/25/24 Deficiency was not cleared. On 4/26/24 bed rail request was submitted for resident #6(R6).On 5/7/24 LPA Flores observed full bed rails on R1's bed, resident is not on hospice. Licensee must either replace rails with half bed rails or request an exception for full bed rails to the department. Resident #3's (R3) bed rails were removed. Bed rail physician's request was submitted to the department on 5/1/24 for resident #2 (R2). No bed rail request were obtained for resident #4. Deficiency not cleared. On 5/21/24 LPA reviewed bed rail request for resident #4 and observed Resident #1's bed rail is a half bed rail. Deficiency cleared as of 5/21/24. (CONTINUED ON LIC 809C) Type B - 87458(b)(1) Medical Assessment - On 4/18/24 LPA observed Resident #5-#6(R5-R6) did not have a TB clearance on file. On 4/25/24 licensee did not provide a copy of TB test for R5-R6. Deficiency not cleared. On 5/7/24 LPA Flores reviewed TB test for R6. No TB test for R5 was obtained. Deficiency not cleared. On 5/15/24 Administrator submitted a copy of TB test for R5 to the department. Deficiency cleared as of 5/15/24. No pending deficiencies to clear for annual visit conducted on 4/16/24 and 4/18/24. Exit interview was conducted with Hongwei He and a copy of this report and clearance letters were provided.