Correction check·June 4, 2024

Licensing Program Analyst (LPA) Galarza conducted an Unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction bed rail citations issued during the 5.23.2024-annual inspection visit. The purpose of this visit was explained to Facility Administrator Briana McGee telephonically because access to the facility was not permitted because the facility entrance gate was closed. LPA called the facility and there was no answer. Administrator arrived shortly after. 87608(a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Licensee did not comply with the section cited above by having 1/2 rails on R1 & R2's beds without a physician's order, which posed an immediate health, safety or personal rights risk to persons in care. 87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. Licensee did not comply with the section cited above in that resident (R3) has full bed rails without being enrolled in hospice, which posed an immediate health, safety or personal rights risk to persons in care. ***The above POCs were cleared by visit. Observations: Resident (R1's) bed rail physician order was obtained on 5/26/2024, but it does not specify the order is for half bed rails. Administrator shall request a corrected physician order. Resident (R2) does not yet have a 1/2 bed rail physician order. No rails were observed on the bed today. Resident (R3's) bed did not have bed rails. A physician order for 1/2 bed rails was obtained on 5/31/2024, but it does not specify that the order is for 1/2 bed rails. Administrator stated that the 1/2 bed rails have not been delivered yet. Resident (R4's) bed had two half rails on 1 side of the bed. A physician order was obtained on 5/30/24. Administrator removed one of the half rails on the side that had 2 half rails installed. Exit interview was conducted with Administrator Briana McGee. A copy of the report was issued.