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25 | LPA Grace Donato made an unannounced annual visit to the facility. LPA met with administrator Michelle Roias. LPA explained the purpose of the visit.
LPA toured the facility inside and outside including resident rooms, common areas, kitchen area and garage. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the dining area having breakfast. A comfortable temperature of 68 deg F is maintained and lighting is sufficient for comfort. Hot water was also tested in the bathrooms and the temperature was 120 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitor is working properly. 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 mats and floor. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. LPA observed sharps, toxins and chemicals to be locked and inaccessible to residents.
LPA reviewed 2 resident records and 3 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. One staff member needs to update first aid training and administrator will schedule for the training.
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. There were expired medications for one of the residents. The administrator took care of it right away by removing the medications and sending it out for disposal.
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