Incident investigation·March 1, 2023

On 3-1-23 at 1:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incidents which occurred on 1-9-23 and 1-10-23. LPA met with Health and Wellness Director Gretchen Monares and explained the purpose of the visit. LPA reviewed incident reports dated 1-15-23 and facility file documentation for resident1 (R1) and R2. LPA also conducted health and safety facility tour as part of this case management. Additionally, LPA interviewed Health and Wellness Director On 1-15-23, facility reported that on 1-9-23, R1 was not assisted with administering medication Methadone 5mg (milligram) as prescribed by Physician. Medication orders reviewed confirmed medication was prescribed with start date of 11-17-22. On 1-15-23, facility reported that on 1-10-23, R2 was not assisted with administering medication Depakote 250mg (milligram) as prescribed by Physician. Medication orders reviewed confirmed Physician orders for medication are dated as of 6/30/22. LPA conducted facility tour with health and wellness director. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Staffing levels included 2 med techs, 3 caregivers, 3 kitchen staff, 4 management staff, and 1 receptionist. Fire extinguisher was full charged and dated 10-12-22. Room temperature was 71*F. Facility is a secured, exclusive memory care unit. Egress door alarms are placed on doors and functioning properly. There is a lobby area leading to a secured, alarmed door leading to memory care unit. Smoke alarms and carbon detectors are functioning properly. Current census is 39. No obstructions to fire exits noted during today's tour. As a result of today's case management visit, deficiencies are cited under Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation within 12-month period. An exit interview was conducted with Gretchen Monares and a copy of this report was left with Gretchen. Appeal rights provided.