Facility Evaluation Report

Licensing Program Analysts (LPAs) Angela Panushkina, Huma Rahimi, along with the Fire Inspector, Frank Madugno and Building Engineering Inspector, Robert Hagen, conducted an annual-continuation inspection and met with the Co-Administrator and explained the reason for the visit.

The facility is Fire Clearance was approved in 10/22/2019 for the capacity of one (1) Bedridden and one (1) Non-Ambulatory residents in room #1, two (2) Non-Ambulatory residents in room #2, one (1) Non-Ambulatory resident in room #3 and one (1) Ambulatory in room #4.

A tour of the physical plant was initiated at 10:15am and the following were observed:

The facility maintains a comfortable temperature at 68°F. The facility has four (4) bedrooms designated for residents’ use. All bedrooms are furnished with beds and dressers and required bedding and linen. The bedrooms have sufficient closet space and lighting. Auditory alarms were tested and observed to be operational. The team observed a twin bed in bedroom #1’ closet. The Co-Administrator informed the team that the staff are using the closet area as a resting area for breaks. The team also observed four (4) bottles of vitamins/over-the-counter medications along with Raid and disinfectant sprays placed on the table, unlocked inside the walking closet. Additionally, self-closing fire door hinge was loose/broken and had a stopper underneath the door to prevent from closing during the emergency. The Co-Administrator was informed to replace/repair the door. Lastly the team observed R1 had a full bed rail with no doctors' order/exception of file, double ½ (half) bed rails (making one full bed rail) for R2 with no doctors' order on file, ½ (half) bed rail for R4 with no doctors' order on file and ½ (half) bed rail for R3 with no doctors' order on file. Deficiency will be issued.