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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Administrator Designee, Lucian Mititti, stating the reason for today's inspection. LPA observed the fire department to arrive at the same time and was advised the facility had just called due to resident (R1) showing a change in condition. (R1) was taken to the hospital. LPA observed (1) resident in the common area watching television and (3) residents in their rooms and was advised there is another resident who is currently participating in physical therapy at a rehab facility. Also present were caregivers, Sharay Burke and Larisa Vornices. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4). Currently there is (1) resident under hospice care. The upstairs area is not used by residents.
LPA and Administrator Designee toured the interior and exterior of the facility including the common areas, (6) resident bedrooms (w/half bathroom each), (2) full bathrooms, kitchen, office, large activity room, staff rooms (2) and laundry area. LPA observed the facility to be clean, in good repair and odor-free, and observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels. There are hand-washing posters at each sink. LPA observed sufficient 2+day perishable, including fresh produce, and 7+day non-perishable supply of food. Sharps and toxins are secured in the kitchen, and resident medications are secured in the office area. The inside temperature measured 73*F and the hot water measured 113*F in a resident bathroom. There are sufficient linens, towels, blankets and PPE supplies, as well as a complete First Aid kit. Smoke/monoxide alarms are working and the fire extinguisher was last serviced 3/11/24. All required posting are visible in the common area. Administrator RCFE certificate #6019173740 is pending renewal. There are cameras in the common area. The facility conducts a variety of activities, including cooking, crafts, holiday celebrations, movies.
LPA reviewed files and medications for (2) residents. Files and documentation were organized and medications being administered match orders. LPA reviewed (3) staff files. All staff are cleared/associated and staff is completing required training, including First Aid/CPR. Updated insurance information obtained. LPA requested a current LIC500 and LIC308 by 11/14/24. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided. |