Facility Evaluation Report

Licensing Program Analyst (LPA) K. Hiratsuka, conducted this unannounced post licensing visit. LPA toured the facility with Staff Member Jordayne Salmon. Administrator Rahel Abebe, arrived and completed visit with LPA.

LPA inspected the resident rooms, bathrooms, common areas, kitchen, and dining room. LPA observed the backyard. The food supply was inspected. The medication records were reviewed. LPA verified staff have first aid and CPR cards.

The following was observed during today's visit:

-medications are prepared for one resident for two days and the second resident for once a week. Per the regulations all medications shall be kept in their original containers.

-no infection control plan in the facility and no staff training for infection control for this facility.

-staff training was all done at a previous facility. Per the regulations staff training has to be facility specific.

-full bed rails on a bed and the resident is not on hospice. Per regulations hospice is the only time full bed rails are allowed.

-residents who cannot determine their need for PRN (as-needed) medications do not have documentation from a doctor that states they cannot

-no plan for emergencies and being self-reliant for 72 hours. And no staff training.

-Licensee does have a training log for a staff person but it has twelve subjects at two hours each and was completed on the same day.