Facility Evaluation Report

An unannounced case management Annual Continuation visit in conjunction with a subsequent complaint visit (Complaint Control # 31-AS-20200428160827 ) was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff Rosa Tonoyan, who contacted administrator Sona Gevorkyan via telephone. Approximately 1:00 pm Ms. Gevorkyan arrived to the facility.

Approximately 12:37 pm LPA conducted a brief tour of the facility and spoke with Staff. While conducting the tour LPA observed the 2 backyard gates exiting the facility pad locked. When touring the facility LPA observed R1 in Rm # 2 utilizing full bed rails. When asked staff stated that they currently have 4 residents on hospice.

From 2:20 pm LPA conducted review of files for 5 residents. LPA requested to review hospice files for residents however licensee did not have complete hospice files for 4 out of 4 residents who are currently receiving hospice services Licensee did not have hospice care plan for R1 indicating the need for the full rail.

A discussion was held with the administrator about ensuring that a complete hospice file is kept at the facility along with copies of hospice visit reports.

At 4:00 pm LPA conducted review of staff files. While reviewing the staff files LPA observed that licensee/administrator is not documenting staff training properly. Staff 1 does not have medication training since start of employment. Staff #2 received medication training from a hospice RN however the licensee/administrator did not have copy of the test taken, or information regarding the training program that was used to provide the training. Staff 3's medication training was from 2019 and documentation missing same information/documentation as staff 2. A lengthy discussion was held with Ms. Gevorkyan regarding documenting staff training, and the requirements of medication training.