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25 | On 9/12/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Caregiver Ryan Galang. LPA explained the purpose of the visit.
LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the living room watching tv and eating snacks. While touring the facility it was observed that the room temperature was at 73 deg F. Hot water was also tested in the bathrooms and the temperature was 118 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms are equipped with grab bars and non-skid 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.
Three resident records and three 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 with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. LPA interviewed 2 residents and 2 staff members.
Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.
LPA requested licensee to submit the following and was received in the facility at 9/12/23: Administrator Certificate, LIC 9282 & LIC 500.
No deficiencies are cited at this time. Report is reviewed with Licensee and a copy is provided. |