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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Robert Kovacs, caregiver, and explained purpose of inspection. Administrator, Eva Nemethy, was contacted and arrived at 3:00 pm. LPA observed (3) residents to be in their rooms at the start of the inspection and (1) resident return during the inspection. There are no residents under hospice.
LPA and the Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (6), resident bathrooms (3), kitchen, staff room and laundry 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, paper towels, soap and 20-second hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and toxins in the kitchen and locked medications and additional toxins in the laundry room. LPA observed the inside temperature to be 73*F. Hot water measured 112*F in the kitchen. Fire extinguisher is scheduled to be serviced by 11/30/24 and has been pre-paid (last serviced 11/11/23). There is (1) unlocked gate from the inside back patio. There are no bodies of water or a pool.
LPA reviewed (2) of (4) resident files and found them to contain the required paperwork. LPA reviewed medications for (1) resident- orders match medications and documentation is being maintained. LPA reviewed (2) staff files. Both staff have current First Aid and another staff has both First Aid/CPR. Administrator to complete CPR training so a second staff is certified. Documentation shows a main staff completed 25+ hours of required annual training in November 2024. Administrator RCFE Certificate is pending renewal. Administrator created a binder (red) for Emergency Disaster Plan and Infection Control Plan today for easy access.
There were no citations issued; however, there are (2) Technical Violations issued.
Exit interview. Copy of report provided. |