Routine inspection·February 26, 2024

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Jane Mikenas, who was informed of the purpose of the visit. At time of visit there were (4) clients and (4) staff present. The facility is a two story home with licensed capacity on the first floor with (3) bedrooms and (2) bathrooms. The facility does not have a pool or fire arms. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following: Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector were operational. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items. Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. (1) on boarding staff did not have a health screening conducted, technical note was issued as all other staff had health screening and appointment had been previously booked for health screening. Licensee agreed to send LPA proof of the health screening when completed. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway cabinet. LPA reviewed client medications and found that MARS and medication had discrepancies. LPA observe medication #1 (M1) was punched but not documented on MARS as given. Medication #2 (M2) was noted for morning, noon and evening, and LPA found all medication was punched out of bubble pack as given. Based on interview, the evening medications are given at 8pm, and at the time of inspection, 2:00pm, the evening medication had been punched as given. Based on staff interview, who admitted making an error, documentation and observation, the facility is being cited for Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 3/5/2023. This was cited and plan of correction was created with licensee. An exit interview was conducted where a copy of this report, LIC809-D, LIC811, appeal rights and LIC9098 were reviewed and provided to, Licensee, Jane Mikenas.