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25 | Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 9/24/24. LPA met with Administrator, Jared Green, and the reason for the visit was explained. The facility is licensed for 85 non-ambulatory residents, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents.
LPA toured the facility, reviewed files and medications using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed:
The facility is a 2-story building that consists of resident bedrooms on both floors. Each floor also has common areas, activity rooms, and communal restrooms. The dining hall and kitchen is located on the first floor. There is a memory care unit on the 2nd floor. The memory care unit has an indoor and enclosed outdoor area for resident recreation activities. LPA selected random rooms to inspect in both memory care and assisted living side. There were no sharps or cleaning products in their rooms. Facility is free of odors from incontinence. LPA observed adequate food supplies of 2 day perishable and a week of non-perishable. The facility receives food supplies twice a week. The kitchen is free of rodents and insects.
LPA reviewed 5 resident files. Resident files have the admission agreement, physician's report, consent forms, resident appraisal, personal rights, and property and valuable form. LPA reviewed 5 staff files. The administrator's certificate expires on 4/14/26. Staff files have the health assessment with TB test result, criminal background clearance letter, and personnel record. Staff are receiving ongoing training. However, LPA provided a technical assistance to ensure staff are receiving the required number of hours on dementia care. Medications are centrally stored in the locked cart. The facility utilizes the electronic medication log to document when given. LPA checked the medications for 5 residents and did not observe any discrepancies.
Facility has the updated Emergency Disaster Plan and conducting quarterly disaster drills for each shift.
No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator. |