Facility Evaluation Report

Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were granted entry by Staff Darlene Ruano. Staff contacted the Administrator who responded to the facility to assist with the visit. LPAs met with Administrator Ramona Eleco.

LPAs toured the facility. LPAs smelled a strong odor of urine and the bathroom counter to be dirty in Room 30. LPAs observed a bed with only the bottom sheet with a brown substance on the bottom sheet of Room 49. LPAs observed the community shower to be dirty with a trash can and a broom inside the shower. LPAs observed Room 50 to have an unknown liquid substance on the floor. LPAs observed cleaning supplies on the bed in Room 51. LPAs observed the foot and head of the bed in Room 53 to be slanting. LPA's observed a dirty diaper on the floor in Room 17. LPAs observed urine on the floor and the hoyer lift in Room 33. Room 67 had a dirty floor. LPAs took photos. LPAs observed R1 in the geri chair for majority of the day. LPA Doucette spoke to R1's family who advised R1 awoled awhile back. LPA's could not locate an awol report submitted to licensing. LPA Miranda did a case management for reporting requirements and incidental and medical. At 6:45 PM LPA's observed R1 in his geri chair unsupervised in the medication room while the medication technician opened the front door in reaching distance of medications.

LPAs toured of the outside of the facility where LPAs observed torn screens and the fascia board to be rotting. The dining exit door to the courtyard is broken. LPAs took photos. Facility has outdoor seating for residents.

LPAs reviewed resident's medication and files. LPAs interviewed staff and residents and found staff are administering injections to residents. R7's physicians report states R7 is unable to administer own injections or check glucose. LPA obtained a copy of R7's LIC602. This was addressed with Administrator on 8/22/23 per inspection notes. LPAs found medication errors for R7 and R8. Facility staff are crushing medications