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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Naomi White, caregiver, and stated reason for the inspection. LPA spoke to the Administrator, Anamaria Documanov, by phone, who stated the lead caregivers would attend. Magda Szanto, lead caregiver and Elena Docmanov, lead caregiver, arrived at approximately 1:00 pm. (3) residents were finishing lunch in the common area. (1) resident was in his room. The facility is licensed for (5) non-ambulatory residents, (1) bedridden resident. Currently there are (0) residents on hospice.
LPA and lead caregivers toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, staff rooms, resident bathrooms, kitchen, and laundry/garage area. LPA observed the facility to be clean, in good repair and odor-free. The bathrooms to have the necessary grab bars, non-skid flooring, paper towels and (20) second hand-washing posters. There is sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and toxins in the kitchen. Medications are locked in a separate cabinet nearby. Inside temperature measured 74*F and hot water measured 118*F in the kitchen. Smoke monoxide alarms work. There is a complete First Aid kit and sufficient linens/towels/blankets. There is one unlocked exit gate. Fire extinguisher was last serviced 10/26/23. There are books/games/activities. LPA reviewed the Infection Control Plan and found it to be very comprehensive. The Emergency Disaster Plan was last reviewed Dec 2023. Both plans are posted, along with other required postings, in the common area. The Administrator's Certificate is pending renewal. LPA reviewed (2) resident files and found them to be organized and contain current paperwork. Medications were also reviewed and no discrepancies were noted. LPA reviewed (4) staff files. All staff are cleared/associated and have current First Aid/CPR. LPA observed much documentation on file for completed training. Administrator to ensure all staff have completed the required initial and annual training in Postural supports, hospice and restricted health conditions. LPA requested updated copy of liability insurance, LIC500 and LIC308 by 2/22/24.
There were no discrepancies noted. Exit interview. Copy of report provided. |