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25 | On 2/11/2025, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced annual visit. LPA met with Assistant Administrator Nikki Montilla. LPA explained the purpose of today's visit.
LPA toured the facility inside and outside including resident rooms, common areas, and kitchen area. Facility has 2 floors. Several residents were having bingo in the dining area. While touring the facility it was observed that the temperature was at 69 deg F. Hot water was also tested in the resident rooms and the temperature was 106 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms were observed to be in good repair and adequate lighting. Bathrooms are equipped with grab bars and non-skid floors. 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 requested the following documents: Liability Insurance, LIC308 & LIC500.
No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided. |