Elder's Ranch by Carla, LLC

Based on observation, documentation review, and interview, the licensee of a health care institution (HCI) failed to submit an application packet for a modification of the health care institution. The deficient practice posed a risk if the Department was unable to verify the licensee had complied with applicable rules and regulations. Findings include: 1. During an environmental inspection, the compliance officer observed an "office/bedroom" had been modified and converted into two bedrooms and a hallway. The surveyor observed both bedrooms had furniture, and appeared to be occupied by residents. 2. In an interview, E1 reported the prior "office/bedroom" attached to the kitchen had been modified, and converted into two bedrooms separated by a hallway. E1 reported a resident occupied in each bedroom. E1 was unaware if documentation regarding the facility modification had been submitted to the Department. 3. During a review of Department documentation, the compliance officer was unable to locate documentation submitted by the provider, to the Department, requesting approval for the modification of the facility.

Based on documentation review, observation and interview, the manager failed to ensure a resident bedroom was not used as a passageway. Findings include: 1. During an environmental inspection, the surveyor observed a resident bedroom with a double doorway from the kitchen, and a doorway to a hallway which led to two resident bedrooms and a common area. The resident bedroom allowed for passage through the bedroom to the hallway, resident bedrooms and common area. 2. In an interview, E1 reported R3 occupied the bedroom by the kitchen due to the need for increased supervision. E1 acknowledged R3's bedroom allowed for passageway to other resident bedrooms, the hallway and common area. E1 reported the bedroom had been an office and was remodeled into two bedrooms and a hallway.