Facility Evaluation Report

Licensing Program Analysts (LPAs) Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Beatriz Ancheta. Administrator Socorro Telmo responded to assist with the visit.

When LPAs arrived staff struggled with unlocking and opening the door. When LPAs entered the facility a separate lock was observed on the front door. LPA asked Administrator why there was a separate lock. Administrator stated they had a resident that wandered and it was to keep the resident in. When LPAs entered the facility there was a smell of urine. Facility had delay egress turned off for the front and garage door. The back door did not have a delay egress. LPA took photos.

A tour of the facility was conducted with Staff.

LPA Doucette observed 6 bedrooms in the facility. While touring the facility, Hot water temperature was measured 106.9 F. Facility is at 76 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked cabinet in kitchen. Cleaning supplies were in a locked cabinet under the kitchen and in locked cabinet in garage. Smoke detectors were checked and operating. Carbon monoxide was not working. Facility has a pull station fire alarm. Fire extinguisher has a service date of 1/11/24.

Resident, medication, and staff records were reviewed. R1's centrally stored log was reviewed and errors were observed. Amlodipine and Esomepradole were not logged on the centrally stored log. Morphine prescription showed quantity of 30 however it was crossed out and handwritten in quantity 52. PRN log shows 34 were given out of the 30 or 52 with 23 left. Morphine start date shows 03/4/24. LPA took photos. Staff did not have hospice training for residents on hospice. Hospice care plans did not meet regulation requirements.