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25 | Licensing Program Analysts (LPAs) Chris Arnhold and Christi Coppo arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Jessica Robles. There were two care givers on duty to provide care and supervision for eleven residents. Facility currently has three residents on hospice which is allowable per the facility's Hospice Waiver for six.
LPAs and Administrator initiated a tour of the facility around 9:20am and made the following observations: Facility was a comfortable temperature. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sink accessible to residents in care measured at 106 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Medications are secure. Kitchen cabinet containing cleaning supplies was located behind 2 baby gates. Facility has at least two days of perishable and seven days of non-perishable foods.
Fire extinguishers were last inspected August 10, 2023. Carbon Monoxide detectors were tested and operational as indicated by Fire Marshall sticker by fire alarm on March 2023. Facility was recently inspected by the local fire department and no issues were noted regarding fire alarms. Last quarterly disaster drill conducted 8/20/2023.
Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Jessica Robles 6063077740 expires 05/16/2024. Medications and medication records were reviewed. Medication record for (R1) had two errors, Systane eye drops were not listed in the correct quantity and Prednisolone eye drops was not on the CRM. Training records were reviewed. Required postings were observed in the kitchen. LPAs confirmed that facility has valid Liability Insurance.
Licensee/Administrator to submit updates of the following documents by 10/30/2023:
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
LIC 308 Designation of Facility Responsibility
Liability Insurance
Infection Control Plan- need recently updated plan
No deficiencies were observed in the areas inspected. No citations issued during today’s visit.
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