Orchard Lake House 4

The 2023 assessment plan for Resident A was not dated by the guardian.

According to Resident A’s MAR, her Diclofenac was documented as not being available on 03/01/25, 03/02/25, 03/04/25, 03/05/25, and 03/06/25. However, the medication was actually available in the home on the above-mentioned dates. It is unknown if Resident A actually received this medication as prescribed.

The funds part II forms for Resident A and Resident B is not being signed by the licensee designee or by anyone appointed by the designee.

During the first quarter of fire drills for 2024, there were only two fire drills completed. An evening fire drill was not completed during the second quarter in 2024. A sleeping fire drill was not completed during the third quarter in 2024. During the last quarter in 2024, an evening and sleeping drill was not completed. During the first quarter of fire drills for 2023, a sleeping drill was not completed. A sleeping fire drill was missing during the second quarter in 2023. During the third quarter in 2023, an evening and daytime drill was missing. A sleeping drill was not completed in the last quarter in 2023.

A 2023 physical was not completed for Resident A. An initial physical for Resident B was not completed.

The licensee designee Erin Gust did not complete her 2024 physical on the correct BCAL required form. A 2023 physical was not provided for review for Ms. Gust.