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25 | At 11:00am on 01/04/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Licensee - Janelyn Castaniaga announced who he is and the reason for the visit.
This facility is has 6 resident bedrooms and 3 resident bathrooms down stairs. There are 4 resident bedrooms and two resident bathroom in the back hall of the facility and 2 resident bedrooms and 1 resident bathroom on the west side of the facility. The bathroom in the back east side of the facility was lacking a non skid mat [873903(e)(5)], and the toilet was not operational [87303(e)(5)] for "about 30 days" according the Licensee, and was not operational when LPA attempted to flush it on the inspection tour. Citation was issued for both violations. LPA toured the entire facility and found the smoke detectors to be in all rooms and functioning and the carbon monoxide detector to be in the back hallway and functioning properly. Fire extinguisher was currently tagged and in the green pressure range. All exits and walkways were free and clear of debit. LPA observed at least 2 days of perishable foods and at least 7 days of non-perishable foods on hand for six residents. LPA observed all rooms to have furnishings, linins, and lighting required by regulation. LPA observed facility has a complete first aide kit. LPA noted that the upstairs has a baby gate at the base of the stairs and there an additional 4 bedrooms and 2 bathroom which are all staff bedrooms and bathrooms.
LPA conducted a sample inspection of resident and staff files. LPA noted that resident files are updated and complete and all staff files are completed with current CPR and 20 hours of annual training with 8 hours of dementia training for each staff file reviewed. LPA conducted a sample medication audit. LPA noted that the review of the centrally stored medication record did not reveal any violations or citations.
Licensee and LPA conducted a full review of the annual control tools modules. LPA noted that only two type B violations were as noted above. At the time of writing this report Licensee had obtained a non skid mat for bathroom 3 and LPA will clear that Plan of Correction (POC). No other technical, violations, or citations were issued as a result of this full annual inspection and full care tools review.
Exit interview, report read, violations cited, appeal rights, and report provided. |