Facility Evaluation Report

Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's were granted entry by Staff Krizia Adajar. S LPA's met with Administrator Nancy Cudal. Licensee Representative Kristine Juarez responded to the facility to assist with the visit.

LPAs toured the facility inside and out. LPAs observed adequate food supply. When entering the facility there was an urine odor. Carbon monoxide detector were tested and are in working order. Facility has pull station fire alarm with sprinkler system. Fire extinguishers were serviced 2/29/24, LPAs observed one extinguisher to not have charge. Water temperature in R3 (128.1) & R5 (139.9) were over the allowed temperature.

LPAs observed the following deficiencies:

Sample of resident files were reviewed- R3's physician report was not complete and was missing DX. Resident files did not have PRN orders from physician, no plan of care for residents with restricted. LPAs observed hospice records which were not complete.

LPAs observed room 38 to have buildup in the shower. LPAs observed broken window, screens missing from windows, and screen torn. LPAs observed ice machine to have mold, on the side of the facility was broken furniture and other items.

Sample of staff files were reviewed and LPAs observed staff training to not be current or documented properly. Licensee did not have documentation for staff training for resident on hospice.

LPA observed a sample of resident's medication which were not recorded on centrally stored log and were not stored properly (R1). R1 did not receive medication from 11/2023 through 4/2024, facility does not have document records for this time period.