Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Operations Manager Maria Constantin was notified upon arrival and joined shortly afterwards to assist with the visit.

LPA reviewed the facility's resident census, staff roster and schedule as well as the Emergency and Disaster Plan and Infection Control Plan. There are 25 residents in care, eleven of which are receiving hospice care at the time of the visit. A sample of six staff records and six resident records were requested and reviewed during the visit. Postural supports are observed to be in use by a number of residents. Hospice plan of care and corresponding physician orders verified to be on file. Admission agreement is missing from one file reviewed, and three others are missing one signature or both signatures. Type B deficiency cited. Consultation provided on fire clearance requirements for bedridden residents. All staff members listed on the facility's roster form are verified to be background cleared and associated to the facility at the time of the visit. CPR training is current for all staff members reviewed. Proof of initial and annual training are kept in Relias and will be provided by staff as soon as possible for LPA review.

The facility is a two-story secure building. LPA accompanied by facility staff conducted a tour of the interior and exterior of the physical plant. A total of 12 occupied units were inspected during the tour. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards.