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25 | Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Executive Director (ED), Michele Johnson, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with ED Michele, observed the facility food supplies, reviewed (5) resident medications, (5) resident files, (5) staff files. The facility is a two-story building with a memory care unit, operating as a Residential Care Facility for the Elderly. It is licensed to serve (148) older adults, ages 60 and over. There is a fire clearance approved for (148) non-ambulatory residents, of which (6) may be bedridden, and includes bedridden rooms approved on both first and second floors and delayed egress. There are currently (2) residents receiving hospice care. It has an approved Dementia Care Plan and a Hospice Waiver approved for (10) residents. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file, as required.
LPA observed random resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shower rooms are equipped with required grab bars and non-skid mats. The hot water was tested and measured at 105*F-108*F, which is in compliance. The facility has a commercial kitchen. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 01/19/2024. The call system was tested in resident bedrooms and were operational. The facility is equipped with surveillance cameras in common areas. (5) resident files and (5) staff files were reviewed and observed to be complete with all required documentation. (5) resident medications were reviewed and were observed to be documented properly and given as prescribed.
No deficiencies were observed or cited, during today's visit.
An exit interview was conducted and a copy of this report was provided. |