Follow-up·November 22, 2021

Licensing Program Analyst Ryker Heberle (LPA) visited the facility to conduct an unannounced complaint investigation. LPA met with facility staff member Andrea Thompson (S1). During phone call with Administrator Sylvester Okoro (Admin), Admin granted permission for S1 to sign written reports on his behalf. During tour of the facility, LPA observed a lock on the facility refrigerator. LPA took pictures of the locked refrigerator. In telephone call with Admin, Admin stated that facility staff placed a lock on the refrigerator on the recommendation of a resident's VA nurse. LPA asked Admin whether or not he had any written documentation, such as doctor's or nurse's orders recommending the use of a lock. Admin stated that he did not, and that the recommendation was received verbally. While inspecting resident rooms, LPA observed medication visible and accessible to resident in room 3. Visible medication was confirmed to belong to the resident residing in room 3 (R1). Records review of R1'a physician's report indicates that R1 cannot administer or store his/her own medications. Deficiencies cited. See LIC 809-D. Exit interview was conducted with S1. A copy of this report along with facility's appeal rights were provided during visit.