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25 | On 09/29/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with manager on duty (MOD) who was authorized by administrator to act on her behalf and signe the reports. LPA explained the purpose of the visit with MOD.
LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 118 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged. LPA reviewed 5 staff and 5 resident files. LPA also conducted 2 staff and 2 resident interviews during visit.
LPA observed the following deficiency during visit:
Expired fire extinguisher (last purchased 11/2021)
Continued on next page, LIC 9099-C |