- Licensing Specialist: Chelsea Vardell.
- Facility visited from 11:50 – 15:00. Census: 46. The Licensing Specialist completed a children record review for 4 residents. Walkthrough completed and MARs reviewed for 3 residents.
- Regs out of compliance –
- R911.6 – Room 202 closet boards should be removed as they can be easily removed by hand exposing nails. Due date: 6/1/22.
- R1014.6 – Escape diagram on the SRU unit is missing. Due date: 6/1/22.
- TA –
- R904.1.p – Individual therapy notes have not been added to the resident’s charts in several weeks. Please ensure that all therapy notes are documented in the resident’s files in a timely manner.
- Regs not correctable –
- R904.1.o – Resident was missing a physician order for 3 chemical restraints and 2 physical restraints, and another resident was missing a physician order for 1 physical restraint.
- R902.10 – All required admission information was obtained the day after admission and not at the time of admission in the file of 1 resident.
- R902.10.b – A description of the reasons for the admission of 1 resident was not obtained at the time of admission (Section for this information was left blank on the admission paperwork).
- R905.17 – Resident was missing restraint justification packets for 1 physical restraint and 1 chemical restraint.
PRLU or OLTC
Children's Records Review, Visit Compliance Report