Follow-up on corrections·August 4, 2021

Licensing Program Analysts (LPA's) Sabrina Calzada and Kevin Mknelly arrived unannounced to attend a meeting between the Ombudsman's office and the facility regarding recent follow up concerns with the current resident council situation. LPA's met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, confirmed with the facility there are currently no positive Covid-19 diagnoses and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. At the conclusion of the meeting, LPA's discussed (2) recent incidences occurring at the facility that were discussed with the Administrator on 7/21/2021 that resulted in the issuance of (3) citations in this report, as follows: 1) On 7/21/2021, staff (S2), Med-Tech, requested that staff (S1), receptionist, assist her in administering 6:00 am medications to resident (R1). Interviews with staff (S1 and S2) and resident (R1) all confirmed that staff (S1), who is not trained in medication administration, administered medication to resident (R1) on the morning of 7/21/2021. Administrator stated she was not aware of this incident but that staff (S1) is trained as a caregiver but has not had training in administering medications. Review of Medication Administration Record (MAR) for July 2021 for resident (R1) documents that medication Carbidopa-Levodopa 25-100 mg was issued to resident (R1) at 6:00 am on 7/21/2021 by staff (S2). 2) On 7/16/2021, resident (R2) was found, at approximately 6:45 -7:00 am, outside in the facility back parking lot, sitting in the front seat of an unlocked and unmarked facility van by staff (S3, S4 and S5) . LPA's inspected the unmarked van on 8/4/2021 and found the doors to be unlocked at approximately 11:00 am. cont on 809C... Interview with staff (S3) who has worked at the facility for (5) years approximately indicated that resident has tried to exit the facility before on her own. Additional interviews confirmed that any exit door opened without the use of the key pad will activate the alarm; however, interviews also indicated that the alarm was not heard when resident (R2) exited at approximately 6:20 am, when resident was found to be missing, as reported on the LIC624. Facility completed an Unusual Incident/Injury Report (LIC624) for the incident on 7/16/2021 and it was emailed to the department on 7/22/2021 when requested. LIC624 stated that resident (R2) was observed to not be in her room when staff was making her rounds at 6:20 am but after a brief search resident was found in the back parking lot. LIC624 indicates that a care conference would be scheduled with resident's (R2) family to discuss the incident and Administrator stated to LPA on 7/21/2021 that she would follow up with resident's family regarding relocating resident to a related facility with a memory care program. Administrator indicated on 8/4/2021 that a recent care conference was conducted with resident's (R2) family to begin the process of relocating resident to a higher level of care. Most recent care plan was also reviewed on 8/4/2021 and it is dated as 7/24/2020. Care plan notes that resident has Dementia but does not mention any wandering tendencies. Physician's report for resident (R2), dated 10/5/2018, notes that resident has a diagnosis of Dementia, is confused/disoriented and is not able to leave the facility unassisted. Physician's report provided to the department today had not been updated within the last 12 months. (deficiency issued in 809D) Based on information obtained from interviews and document review, the following (3) citations are issued per Title 22 Regulations, Division 6, Chapter 8. See 809D pages for citations issued. Exit interview. Copy of report and appeal rights provided.