Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver, LVN. Administrator not available to come to the facility but was available periodically via telephone.

At approximately 9:00am LPA and caregiver toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Black substance present in grout and spotted black film around sink in grout, LPA observed the same issue during last annual inspection dated 3/22/24 ( deficiency cited, see 809D ). Thick-it food and beverage thickener found in the pantry with prescription label torn off and date of expiration covering where label was. LPA advised this is a prescription item and cannot be shared between residents that do not have a prescription. LPA found zinc oxide and vitamin C in hall closet, unlocked and accessible to residents. LPA advised all vitamins and supplements must be stored inaccessible to residents.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms in good repair; however, there was a pervasive odor of urine incontinence present in the facility, coming from rooms #1 and #3 ( deficiency cited, see 809D ), odor was noticeable immediately upon entering the facility. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Bathroom in room #4 has a shower that has brown substance present in shower and chunks of a white substance concentrated over the drain. LPA advised caregiver, LVN that even if the shower is not presently used, it should remain clean. Water temperature in sink accessible to residents in care measured at 113.6 and 107.1 and degrees F which is within the allowable range of 105 to 120 degrees F.