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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Annastaycia Kelly, caregiver, who contacted Vera Okyere, Administrator. LPA spoke to the Administrator and explained the purpose of today's inspection. Administrator stated she was at the hospital currently with a resident and would arrive shortly. Administrator and resident arrived at 12:40 pm. LPA observed (3) of (4) residents present in the common areas and (1) resident remained in his room during for inspection.The facility is licensed for (6) non-ambulatory residents. (1) resident is on hospice.
LPA and Administrator toured the interior/exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (2) resident bathrooms, kitchen, staff room and laundry/storage area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, electronic paper towel dispenser and 20-second hand-washing posters. LPA observed sufficient 2+day perishable, including fresh produce and salad mixes, and 7+day non-perishable supply of food, Sharps and medications are locked in the kitchen and toxins are secured in the laundry area. Inside temperature measured 70*F. Fire extinguisher was last serviced 12/12/22- will be serviced again by 12/12/23. Hot water measured 108*F in a guest bathroom but measured 140*F in the kitchen. Administrator to post a sign by the kitchen sink. There are birds and fish in the common area. LPA observed sufficient linen, blankets and incontinent/ PPE supplies on hand. Administrator certificate #6044860740--exp 8/14/23 is pending renewal and was submitted timely to the Department. There is (1) unlocked gate from the inside back patio and no bodies of water. Required postings are up. Administrator to ensure that (30) Personal rights are posted and visible.
LPA reviewed (2) resident files and observed them to be organized and contain required/current documentation. Medications were reviewed for (2) residents. Orders were compared to medications being given and no discrepancies were noted. Medication documentation is complete. LPA reviewed (3) staff files. Staff regularly receive ongoing training, and new staff have begun initial training. First Aid/CPR is current. All staff are cleared/associated and roster was recently updated and sent to the Dept. LPA requested updated copy of LIC308, LIC500 and current liability insurance. LPA to provide LIC9282 for Administrator to complete/return by 12/8/23. There are no deficiencies issued but there is a Technical Advisory Note being issued. Exit interview. Copy of report provided. |