Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 11:16 AM. LPA met with the facility staff who contacted the Administrator Gabriela Visovan. The Administrator arrived to the facility at approximately 11:45 AM entrance interview conducted and the reason for the visit was explained. The following was observed:

RECORD REVIEW: Record review began at approximately 11:35 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. All resident files reviewed contained all required documentation and signatures. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 12:59 AM. Medications are stored centrally and securely in the medication room. Medications for five (5) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The last emergency disaster drill was conducted 06/10/2025. The facility’s emergency disaster plan is up to date and adequate. Both the infection control plan and emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

No deficiencies were cited at the time of the visit. Exit interview conducted. And a copy of the report was provided.