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25 | Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assistant Administrator, Alexis Salvador Varela Lopez. According to the facility’s license, the facility has a maximum capacity of fourteen residents, of whom all may be non-ambulatory, waiver granted for hospice care for 8 residents, and dementia plan submitted.
Along with facility staff, LPA D. Roman toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Resident beds were observed to have full bed rails, hospice care plans were not available to justify the need for full bed rails. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were toxic chemicals/poisons accessible to clients stored under the bathroom sink of one resident restroom. Medications were labeled, as required, and stored in locked areas. Water temperature of 130 degrees F, exceeded regulatory measures of 120 degrees F.
No pools or bodies of water on the premises. Per Assistant Administrator, no firearms or ammunition are kept at the facility. Smoke/Carbon monoxide detectors tested at 3:30PM, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Resident records reviewed lacking required documentation. Resident records lacked admissions agreements, physician reports, needs & services appraisals. Staff records reviewed lacked training verification.
(Cont. on LIC809-C)
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