Facility Evaluation Report

On 03/27/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Jean Asignacion via telephone. Administrator arrived a short time later.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. LPA observed a long, wooden stick on the track of the sliding door in the dining room. Resident rooms appeared clean and had required furnishings. LPA observed medications on the counter in the bathroom in bedroom 4 and nutritional supplements on a dresser in bedroom 3. Medications and nutritional supplements were accessible to residents in care. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured between 112.6 degrees F and 117.2 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 04/12/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has not conducted a fire/emergency disaster drill.

LPA reviewed staff and client records. Upon review of resident records, R2 did not have an updated physician's report. LPA also found that 3 out of 4 residents receiving hospice services did not have a care plan on file. LPA observed that 3 out of 3 staff did not have training specific to each resident on file. Upon review of staff files, LPA found that 3 out of 3 staff did not have a complete personnel file, multiple documents appeared to be missing, including the health screen, employee rights, and personnel record. LPA also found that 2 out of 3 staff did not have updated training.

Medications reviewed and observed to have original labels and be administered as prescribed. LPA observed multiple medications that had been discontinued stored in a cabinet near the stove. Administrator stated, the medications are "old" and need to be destroyed.