Facility Evaluation Report

At 09:30am Licensing Program Analysts (LPAs), Angela Panushkina and Michael Cava, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20250916083845 and #31-AS-20250919120442. LPAs were greeted by the staff, Emma Rodriguez, who granted access to the facility. LPAs attempted to contact the Administrator, but no one answered.

LPAs were informed that the facility has five (5) non-ambulatory, four (4) of which are currently receiving hospice (R1, R3, R4 and R5) and one (1) resident is receiving Home Health. Fire Clearance was approved for six (6) Ambulatory ONLY residents.

At approximately 9:35am LPAs conducted a tour of the facility, and the following were observed:

Kitchen: LPAs observed insufficient supplies of staple non-perishable for 1 week and perishable for 2 days. LPAs observed Clorox along with other chemicals and detergents under the kitchen sink were kept unlocked and accessible to residents. There is a fire extinguisher by the kitchen and LPAs observed the arrow on a meter was still on a green area, indicating that it was fully charged. Smoke alarm is operational however the carbon monoxide detector is inoperable.

Bedrooms: There are three (3) bedrooms designated for residents’ use and have sufficient lighting. All bedrooms have appropriate bedding and linens. Between 9:45am and 9:55am, LPAs observed walls to be poorly scraped up in all three (3) bedrooms. LPAs also observed R1, R2, R3, and R5 had full bed rails, and R4 had ½ bedrail. Physician's order for half/full bed rails were not available upon request.