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25 | On October 31, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit.
LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story facility with Memory Care on the first and half of the second floor and Assisted Living on the other half of the second floor and third floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed some residents doing activities with staff or watching television. A comfortable temperature is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 111-119 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars and built-in non-skid mats in each bathroom.
LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications, sharps and chemicals were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. First aid kits were observed present and complete.
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 requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.
The following documents are requested to be submitted to CCL by 11/7/24:
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan
-LIC500 Personnel Report
No deficiencies are cited at this time. Report is reviewed with Administrator and copy is provided. |