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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met Rose Mead, Administrator. Caregiver, Rowena Tirasol, was also present. LPA observed (2) resident in the common areas and (2) residents to be in their rooms at the start of the inspection. The facility is licensed for (5) non-ambulatory residents, (1) ambulatory and has a hospice waiver for (3). Currently, there is (1) resident on hospice.
LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (2) resident bathrooms, (1) staff room, kitchen and laundry area, and office 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 and hand-washing posters. There is sufficient 2+ day perishable and 7+ day non-perishable supply of food. Sharps, medications and toxins are locked in the kitchen/laundry area. The inside temperature measured 71*F, and the hot water temperature measured 108*F in the kitchen. Facility conducts quarterly fire drills. Smoke/monoxide alarms are working. LPA observed (2) unlocked gates from the outside patio and also covered patio seating. There are sufficient towels/linens/PPE/paper and incontinent products. All required postings are in the common area. Administrator to ensure the most updated copy of personal rights (LIC613C) is posted. First aid kit is complete. LPA reviewed/approved the Infection Control Plan and found it complete.
LPA reviewed (3) resident files and found them to be complete with current physician's reports and care plans. Medications were reviewed for (2) residents and orders matched medications being administered. A Technical Advisory Note is being issued. Documentation is clear and current for medications. LPA reviewed (2) staff files. Files were organized and training is current with documentation, including First Aid/CPR. All staff are cleared and associated to the facility. RCFE Administrator certificate #6014576740 is pending renewal. LPA requested an updated copy of the LIC308, LIC500 and current liability insurance be provided by 4/2/24. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided. |