Facility Evaluation Report

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management visit at 9:45 a.m. for the purpose of conducting a quarterly visit focusing on Policy Development and Implementation in relation to the Stipulation and Waiver; Order adopted by the Department on 09/18/2025. The LPA met with Executive Director (ED) Mark Ranno and Director of Resident Care (DRC) Karen Pasten and explained the reason for the visit.

During today's visit, LPA and the staff toured the physical plant area inside and out to ensure there were no immediate health and safety concerns. Facility records and files were reviewed for, but not limited to: Wander Guard binder, Compliance binder, medication administration records (MAR's), observation and evaluation of residents, scheduled reassessments report, quarterly audits of resident and employee files, monitoring resident emergency alert calls, Ciscor alarm exception report, and alarm exception review log.

At the time of the visit the medication administration records (MAR's) was observed to be completed within the first seven days (7) of the current month in reviewing the prior months MAR. (10/2/2025 - 10/7/2025 ; 11/4/2025 - 11/6/2025 ; 12/3/2025; 01/05/2026 - 01/06/2026) which included medication name, dosage, dates, times, administering staff, missed doses, refusals, and offsite status. Side effects, errors, and drug reactions on the back of MAR or in nurses' notes. Verification of staff training and certification prior to medication administration. All records in order.

Observation and evaluation of residents and scheduled reassessments report, dated 9/2/2025, 10/7/2025, 11/3/2025, 01/1/2026, 01/3/2026. All records in order.