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32 | Staffing: A total of nine (9) caregivers including the (2) Administrators provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Administrator certificate is valid and expires on 12/23/2024, renewal has been submitted in September 2024. Four (4) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training.
Resident Records-Incident Reports: Six (6) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed.
Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full bed rails were reviewed in (1) resident file who is under hospice care. Four (4) other residents use 1/2 bed rail with physician orders, but one (1) resident did not have the order on file.
Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation.
Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Medications reviewed for all (6) residents.
Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Currently, (4) residents receive Home Health care in the facility. Residents medication are centrally stored in a locked cabinet next to the kitchen area.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis.
Residents with SHN: One (1) resident receive hospice care. Appraisals were observed in resident files. No residents have prohibited health conditions.
Deficiencies cited, exit interview conducted and a copy of the report along with the appeal rights were provided to the Administrator, Diana Castellanos. |