Facility Evaluation Report

Licensing Program Analyst (LPA) Amy Goldenberg arrived at 0845 unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

LPA began review of resident records. Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. R2 is missing a physician's order for 1/2 bedrails. LPA observed two 1/2 rails on the bed of R2. Resident Rights are posted in the facility and a copy is signed on file. Dementia and hospice regulation requirements are being met.

LPA began review of employee records. Three (3) records were reviewed. LPA reviewed employee record for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 107 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities tour revealed bleach and laundry soap unlocked and accessible to residents. Fire extinguishers are charged, mounted and current. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications, however, LPA observed that the medication cabinet lock does not prevent access to others. LPA was able to open the medication cabinet. It is only secured with a baby type device and is easily opened by non employees and residents. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. Review of resident records revealed that the facility is not in compliance with their approved fire clearance. R2 is identified on their physicians report ad bedridden. This facility does not have a bed ridden fire clearance.