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25 | Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Juliana Soriano. Administrator, Consuelo Banting arrived during the visit.
LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, and sanitary, but not in good repair. Bedroom #2's doorway is difficult to open and close, requiring repair, and there's a leak in the bathroom #3's shower, which is filling up a bucket placed in the shower. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, and toilets, were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. However, the facility does not have N95 masks. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 111 F..
There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were not in compliance as staff are pre-pouring medications, medication was spilled out in the medication cabinet, PRN medications did not have physician's orders on file, and staff are not documenting PRNs once dispensed.
No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Not all required licensing postings were present. LPA reviewed multiple staff and resident records/files, which were incomplete and did not contain required documentation. Facility did not have a fire extinguisher available for fire emergencies. Residents are using half and full bed rails without a physician order on file.Staff are not trained annually on the emergency and disaster plan. Staff do not have required training documented.
Deficiencies were observed or cited during today's annual inspection along with Technical Advisories. An exit interview was conducted with Administrator, Consuelo Banting to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. |