Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:56 AM to conduct a case management-deficiencies visit at the facility today. LPA met with facility staff who contacted the Designee Hasmik 'Jasmine' Khachatryan. The Designee arrived to the facility at 10:07 AM. Entrance interview was conducted and the reason for the visit was explained.

During today’s visit, the LPA conducted a physical plant tour, conducted a file review for three (3) residents and one (1) staff member, obtained copies of pertinent documentation, and conducted a medication review for three (3) residents between approximately 10:15 AM and 02:40 PM.

During the physical plant tour LPA observed ongoing construction taking place in the back yard of the facility. LPA observed two (2) emergency exit doors attached to resident bedrooms that led to the backyard of the facility where construction was taking place. LPA observed auditory alarms installed on these doors which were not turned on and did not alert when the door was opened. LPA notified the facility staff and Designee who immediately turned on the alarms. LPA reviewed three (3) resident files and observed that one (1) resident was diagnosed with Major Neurocognitive Disorder. Additionally, LPA observed a ramp railing located at the front entrance of the home to be improperly secured. LPA notified the Designee who agreed to perform repairs to the identified railing.