Non-compliance follow-up·June 20, 2024

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10:00AM to conduct a non-compliance inspection. LPA followed up on the following areas which were initially addressed during a non-compliance meeting dated 07/21/2021. LPA met with Executive Director, Ric Pielstick. Medications: Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. During tour of Assisted Living tour, LPAs observed an unlocked cabinet in R1s apartment, which contained PRN medications. LPAs confirmed that R1 was allowed to dispense their own medications per their physicians report. Prohibited Conditions: Facility retained a resident with a prohibited condition. 10 of 10 files reviewed did not have evidence of any residents being retained with a prohibited condition. Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident reports and confirmed that facility has been seeking timely medical attention. Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPAs reviewed 10 resident files that had all required documents. Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPAs reviewed 10 resident files that had all required documents. Continued on LIC809C Continued from LIC809 Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPAs reviewed staffing schedules for both Memory Care and Assisted Living. LPAs reviewed staff training records which indicated staff are receiving 20 hours of annual training as required per regulation. Facility Food Services: Facility kitchen area was toured by LPAs and Chef. LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. LPAs observed dry goods in boxes on the floor in walk in closet. Chef confirmed that staff was in the middle of reorganizing since their previous chef was terminated. Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. Incident reports reviewed revealed that facility has been reporting timely. No deficiencies cited during inspection.