Facility Evaluation Report

Licensing Program Analysts (LPA) Shawna Doucette and Miriam Flores arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Assistant Administrator Janice Johnson. LPA explained the purpose of the visit and Administrator Abraham Mathew responded to the facility to meet LPA's to conduct the visit.

LPA toured the facility which included memory care and assisted living. The facility was set at 73 F temperature and free of passageway obstructions inside and outside.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication room in a locked medication cart. Cleaning supplies were in a locked storage room. Smoke detectors and carbon monoxide detectors are hard wired with a fire panel and pull station fire alarm. Facility has a fire sprinkler system. Fire extinguishers were charged and had service dates of 10/11/23. LPA checked water temperature in 6 resident's rooms to be between 109.6 F to 126.1 F.

There was outdoor seating for the residents.

Resident's files, medication and staff records were reviewed. Medication errors were found. Current first aid and CPR were reviewed. Facility did not have hospice care plans or home health plans for residents in care specificly outling facility responsibilities and hospice/home health responsibilities. Facility did not have current LIC602 physicians report for residents.

A copy of this report with plan of correction and appeal rights were provided to the Assistant Administrator.