Facility Evaluation Report

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Socorro Telmo.

During yesterday's visit LPA's toured the facility. LPA Doucette observed 4 bedrooms in the facility. While touring the facility, LPA observed an added staff bedroom/office/garage which was not on the facility sketch and was not fire cleared. Facility had two different facility sketches posted in the facility. The first sketch did not identify a caregiver room. The second sketch identified the caregiver room as bedroom 1 where residents reside. LPA pulled the sketch from licensing file which does not identify a caregiver room. The staff bedroom/office/ garage contained a fully made bed with sheets and blanket, a recliner and filing cabinets. Facility did not have plan of operation at the facility.

Hot water temperature was measured 115 F. Bathroom did not have skid mats but had grab bars. Facility staff purchased skid mats during visit.

Kitchen toured, supply of food observed. Carrots were expired October 2023. Knives were locked in kitchen drawer. Medications were stored in a Medication cart which was found to be unlocked in the dining room. Refrigerator for medications were found to be unlocked containing morphine and insulin in the dining room. LPA's took photos. Cleaning supplies were in a locked cabinet under the kitchen and bathroom sinks. Smoke detectors and carbon monoxide detectors were checked and operating.

Resident, medication, and staff records were reviewed. R3's centrally stored log was reviewed and errors were observed. One of R3's narcotic medications was not logged. R1's records were reviewed and it was found that R1 self administers injections. R1 had a sharps container in a shared room with R2, which made sharps accessible to R2. Facility does not have a Home Health Care Plan for R2. Facility did not have a Hospice Care Plan for R4.