Facility Evaluation Report

Licensing Program Analysts (LPAs) Angel Ascencio and Ashley Morgan conducted a Annual Continuation on the above facility. The initial annual was conducted on 06/12/2023. LPAs met with Director of Resident Care Services (DRCS) at 09:15 a.m. Entrance interview conducted.

Resident Files: The LPAs observed ten (10) resident files. All files contained the proper documents necessary to stay in compliance.

Staff Files: The LPAs observed ten (10) staff files. All staff files contained the proper documentation to be in compliance within state regulations.

At 1:40 p.m. the LPAs interviewed five (5) staff members. No immediate concerns noted during the interviews.

MEDICATIONS: Medications review began at 12:00 p.m. The LPAs reviewed medications for five (5) residents. Facility maintains a medication room, and medications are kept locked and inaccessible. For one resident (Resident #1) had an as-needed medication (Acetaminophen) that was administered two (2) times since 6/2/2023; however, staff documented that R1 was assisted with this PRN medication one (1) out of two (2) times. For three out of five residents (Resident #2, Resident #3, Resident #4), the pill count was off during the medication audit.

At 1:37 p.m., the LPAs observed accessible medications in an unlocked office. The office was locked at the time of observation.

At 4:00 p.m., the LPAs observed expired bread, expired milk, uncleaned kitchen area, food (bread, pies) not covered putting at risk for contamination, and cleaning substances stored within the food storage area.