Facility Evaluation Report

On 6/19/2024 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Octavian Mahler and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents, of which 6 residents may be bedridden, and 6 residents may be under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and purchased on 6/19/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 113.2 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan. Last disaster drill was conducted on 5/29/2024.

LPA reviewed 5 resident and 4 staff files starting at 10:00AM. LPA interviewed 2 residents and 2 staff. LPA reviewed a sample of resident's medications starting at 12:30PM.

At 9:15AM, LPA observed unlocked medication in the refrigerator. Staff locked up the medication in a lockable refrigerator during inspection. LPA also observed unlocked medications in R3's room and staff locked up the medications.

At 11:00AM, LPA observed S4's file was incomplete.

At 1:00PM, LPA observed facility does not have MAR (Medication Administration Records) for resident's PRN medications.