Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual continuation inspection. LPA met with Administrator Assistant (AA), Makel Ali.

During the initial annual inspection on 08/04/2023, LPA observed the men's and woman's shower room contain multiple black spots on the grout of the walls/ceiling and orange rust on the shower tiles. During today's visit, LPA observed the men's and women's shower room did not contain black spots on the grouts of the wall/ceiling and shower tiles were observed clean.

LPA entered the medication room to follow-up on concerns from the initial visit on 08/04/2023. On 08/04/2023, LPA and staff (S1) observed 5 residents centrally stored medication record (CSMR). LPA observed two of resident (R1)'s medications were not listed on the CSMR, did not include a start date on the record, the expiration date on the bottle was ineligible due to faded print, and the expiration date was not written on the CSMR. During today's visit, LPA encountered the same concern. Facility was advised.

LPA reviewed 5 out of 5 residents files. 5 out of 5 residents appraisal/needs and services plans were not signed by all parties. 5 out of 5 residents files includes an admission agreement, physician's report, TB result, emergency identification, personal rights, safeguard for personal properties and valuables, and safeguard for cash resources. The facility did not have an extra key to the file cabinet where the resident's secured P&I money was located because the responsible staff is currently on vacation. LPA was unable to inspect the residents P&I money during visit. Facility has a plan to ensure resident's are provided their P&I money throughout the week. SEE LIC809-C.