Routine inspection (multi-day)·September 10, 2024

On 9/10/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to continue the annual inspection. LPA introduced herself and was allowed entrance by staff. Licensee Rajvinder Samra was contacted and arrived at the facility shortly after. LPA reviewed medication for R1, centrally stored log and PRN log did not match for Benzonatate oral pill 100 mg capsule. PRN log total was 21, MARs showed medication was also given in August but was not marked on the PRN log. Amlodine oral pill 5 mg tablet was logged as starting 8/21/24, there was 21 marked as taken, and there are 10 remaining in the bottle, which totals 31 pills, the quantity on the medication is 30. When LPA arrived and reviewed the MARs it did not indicate AM medications were given. Citation issued for Centrally stored medication log and PRN log not being kept maintained. Licensee explained due to having the facility sprayed for pests non-perishable food was removed and limited food was kept at the facility in order to not contaminate. LPA accepted the explanation for limited food at the facility. Licensee also explained this is the last week at the facility while renovations are taking place. LPA informed Licensee to submit an incident report and verification of building permits. Licensee stated they will be increasing their capacity to 12 after the renovations, LPA informed Licensee there needs to be documents submitted to request the increase. Citation was issued for the pest/insect control issue from the 8/17/2024 visit. Citation was also issued due to emergency exits not opening properly. LPA reviewed a sample of resident files which are current except for R1's PRN blank prescription form. A sample of staff files was also reviewed which is current and up to date. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Licensee Rajvinder Samra.