| BATHROOMS: There are two (2) total bathrooms; one (1) is in the hallway for common use and one (1) is attached to Bedroom #4. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were between 107.6-111.6 degrees F.
COMMON AREAS: This includes the living room, dining room, and break room. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed a fireplace in the break room that was adequately screened. Facility was maintained at a comfortable temperature. LPA observed storage space closets in hallway containing clean linens for resident use.
OUTDOOR SPACE: The backyard had a covered area with furniture including a table and chairs. There were no bodies of water on the premises. One (1) side pathway is used as an emergency exit which was free of obstruction and had a self-latching gate. There are surveillance cameras in the outdoor perimeter.
MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the kitchen. LPA began medication review at 01:43PM and medications for two (2) residents were observed. At 01:55PM, LPA observed medications for Resident #1 (R1) stored in a pill box organizer and not in its original packaging with labels. Medications for R1 were prepared for 48 hours in advance, and not 24 hours. LPA also observed unopened PRN medications for R1 that expired in June 2025 and August 2025. Administrator stated that all expired medications will be destroyed. All other medications were labeled and maintained in compliance with label instructions, and state and federal law.
RECORD REVIEW: LPA began record review at 02:05PM. LPA reviewed five (5) out of five (5) resident files and four (4) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All resident and staff files were complete and had no missing documents.
INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated as required.
During today’s visit, LPA obtained a copy of the facility’s liability insurance.
No deficiencies cited at this time.
Exit interview conducted and a copy of the report was provided.
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