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25 | On 7/11/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Bridget Kelly and explained the purpose of the visit.
LPA toured the facility inside and outside including a random sample of resident rooms, common areas, activity room and kitchen area. LPA observed most residents engaged in different activities like morning exercise and bingo. While touring the facility it was observed that the temperature was at 70 deg F. Hot water was also tested in the resident rooms and the temperature was 119 deg F. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors and strips. Resident call pendants are functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.
Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.
LPA received the following documents: Liability Insurance, LIC308, LIC610E. A copy of the Control of Property will be emailed to LPA.
No deficiencies are cited at this time. Report is reviewed and a copy is provided. |