Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management POC visit and met with Administrator (ADM) Joseph Lansana. LPA stated the purpose of the visit. LPA observed 5 residents and 3 staff during visit.

On 1/21/2025, LPA Tarin conducted the facility's annual inspection. During visit, LPA measured water temperature in resident bathroom 1 at 133.1 degrees F. LPA also observed during review of Centrally Stored Medication and Destruction Records (CSMDR's) with ADM, that Resident R3 did not have a CSMDR for 8 prescription medications. Two deficiencies were issued and the Plan of Correction (POC) was developed with the ADM. The POC was due on 1/22/2025. The Department received the POC from the ADM on 1/22/2025.

LPA measured water temperature in resident bathroom 1 at 116.9 degrees F at 3:20PM.

LPA reviewed CSMDR for resident R3 and observed a CSMDR for April 2025 with medication documented.

LPA cleared the deficiencies cited on 1/21/2025 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM during today's visit.

No deficiencies were cited during todays visit. A copy of this report was provided to ADM Joseph Lansana.