Print Inspection: J98K

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to immediately notify the Department's Central Office of severe interruption of physical plant services. Findings include, but are not limited to:

Compliance Specialist (CS) reviewed an email sent to Staff 1 (ED) dated 01/25/24 notifying him/her that the fire panel in Cottage C suffered a complete failure. Reviewed another email from the Department dated 02/23/24 notifying the facility that they had just become aware of the situation and the facility had failed to notify the Department immediately.

In an interview on 03/11/24, Staff 1 (ED) stated the fire panel had been reported to him/her from maintenance, however, s/he was not aware that was something s/he needed to report to the Department.  

On 03/11/24, findings were reviewed with and acknowledged by Staff 1.

The facility failed to immediately notify the Department's Central Office of severe interruption of physical plant services.

Verbal plan of correction: Supervisor went over the reporting requirements with the ED so that s/he knows what and when to report to the Department in the future.

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to:

Resident 1's medication error report dated 01/15/24, January 2023 Medication Administration Record (MAR), progress notes, and physician orders, indicated that on 01/15/24, s/he was given another resident's insulin dose in error. Resident 1's order was for 0.5 ml (3 mg) Sub-Q once every week on Monday, however, s/he was given another resident's Trulicity dose of 1.5 ml in error.

During an interview, Staff 1 (ED) stated there were portable lights in the med room during a power outage and the MT reported the wrong dose was given because s/he couldn't see.

The findings were reviewed with and acknowledged by Staff 1 on 03/11/24.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: Better lighting was provided to the med techs during the power outage. The Director of Nursing and the ED have been working on trainings with staff on policy and procedures as things come up, including ensuring the right medication before administering to the residents.

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to maintain their fire detection and protection equipment. Findings include, but are not limited to:

Compliance Specialist (CS) reviewed an email sent to Staff 1 (ED) dated 01/25/24 notifying him/her that the fire panel in Cottage C suffered a complete failure.

In an interview on 03/11/24, Staff 1 (ED) stated the company requires 3 quotes before approving a purchase. S/He stated the part had been ordered and should be arriving on 03/22/24. Staff 1 also stated fire watch was being done every 15 minutes.

On 03/11/24, findings were reviewed with and acknowledged by Staff 1.

It was confirmed the facility failed to maintain their fire detection and protection equipment.

Verbal plan of correction: The facility has ordered the part needed to fix the system which will arrive on 3/22/24. The repair is scheduled for 3/25/24. In the meantime, they have a safety plan in place. Fire watch is on every 15 minutes and is being reported to the Fire Marshall.