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25 | On 07/23/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the care tool. LPA met with Administrator Madelyn Rojo and explained the purpose of the visit.
LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to four (4) resident bedrooms, one (1) bathroom, kitchen, garage, common areas, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. Hot water temperature was measured at 105.1 degrees Fahrenheit at the bathroom sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 77 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in kitchen, which was last serviced on 01/23/24. LPA reviewed drill logs, which are conducted monthly. LPA observed required Licensing posters posted throughout the facility.
LPA reviewed three (3) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, and resident's rights. LPA reviewed two (2) staff records. Staff has training in infection control, first aid/CPR, and other various areas of care provision. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for one (1) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR).
LPA requested for a copy of LIC308 to be emailed to LPA by 07/26/24.
No deficiencies are being cited during today's inspection.
Exit interview conducted and copy of the report was left at the facility |