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25 | On 02/12/25 , Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived unannounced to conduct the annual inspection. LPAs met with administrator, Stephen MacDonald and explained the purpose of the visit.
LPAs toured facility with to ensure the health and safety of residents in care. LPAs toured residents rooms, medication room, bathrooms, kitchen, dining room, common areas and activity areas. LPAs observed residents in common areas participating in activities and in the dining room having lunch. The facility was found to be clean, safe, sanitary and in good condition. LPAs observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. Inside temperature was 72-74 degree F. Hot water measured between 110-114 in three different areas at facility was in required range 105-120 degree F. Facility was conducting fire and disaster drills per requirement.
LPAs reviewed ten (10) residents files and ten (10) staff files. Staff records reviewed indicated training completed and other required paperwork. Residents files found to have required documentation. LPAs reviewed two (2) residents medications comparing with current physician orders and found it to be correct.
LPA checked the current narcotic medications log with staff and found no errors. LPAs observed that medications were secured and were inaccessible to residents.
LPAs completed the full care tool and no deficiencies were observed or cited per Title 22 Regulations.
Exit interview conducted and a copy of the report was left at the facility. |