Follow-up on corrections·June 23, 2021

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to investigate two complaints (#18-AS-20200803114859 & #18-AS-20210616082012). During LPA Colvin's investigation of the complaints, LPA Colvin observed some additional deficiencies. LPA Colvin met with Substitute Administrator Yusef Nofal and advised him of the purpose of the visit. LPA Colvin had previously received Physician's Reports from the Licensee for the purpose of this investigation, which LPA Colvin reviewed. During the review of these medical documents, LPA Colvin observed that five (5) out of eleven (11) residents required some form of assistance or supervision with bathing (R1, R2, R3, R4, & R5). In LPA Colvin's initial interview with both staff and the Licensee/Administrator, it was relayed to LPA Colvin that the residents are able to bathe themselves independently and do not require the facility to provide any kind of monitoring, with the exception of R5. From LPA Colvin's review of the Physician's Reports provided by the Licensee/Administrator, LPA Colvin determined that this information is either inaccurate, or that the residents require a reappraisal of their needs and services that the facility needs to provide them. During today's inspection, LPA Colvin reviewed the file for R2, the only resident of the four noted who still resides at the facility. LPA Colvib observed that in R2's Pre-Admission Appraisal that it was documented (page 2, under "Services Required") that R2 requires assistance from staff with showering. Since both the Licensee and direct care staff have stated to LPA Colvin that they do not provide R2 with assistance with bathing, they are not providing services required in accordance with the appraisal of R2's needs. Deficiency cited. Additionally, LPA Colvin observed that R2 has not had an updated Needs & Services Plan since admission to the facility back in 2019. Considering that there is debate or concern over R2's need for assistance in certain areas, it is especially troublesome that an updated Needs & Services Plan has not been created for R2 and evaluated with R2 and their responsible party (if any). Deficiency cited. Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on the LIC809D. A copy of this report was provided along with LIC809D and appeal rights during the exit interview with Substitute Administrator Yusef Nofal.