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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Administrator, Titus Popa. LPA stated the reason for today's inspection. LPA observed (3) residents in the common area and (3) residents in their rooms during the inspection. Also present were staff, Ted Popa and Valerie Popa. The facility is licensed for (6) non-ambulatory residents and has an approved hospice waiver for (4) residents. Currently there are (3) residents on hospice.
LPA and Administrator toured the interior/exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (3) resident bathrooms, kitchen, office, staff rooms and laundry/garage area. The laundry/garage and staff room area always locked. The facility was clean, in good repair and odor-free, and the bathrooms have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+day perishable and 7+day non-perishable supply of food, including fresh produce, and sharps are locked in the kitchen. Medications are secured in a nearby cabinet and toxins are secured in the laundry room. Inside temperature measured 75*F and hot water measured 108*F in the kitchen. Fire extinguisher was last serviced on 1/21/2025, and the smoke alarms are functioning. There are activities/games with sufficient indoor/outdoor space, including a walking track on front patio and covered seating on back patio. There are (2) unlocked exit gates. Updated lain-line obtained.
(3) resident files were reviewed and found to be organized and contain current documentation. The care plans were last updated in January 2025 and physician reports were completed within the last (12) months. Medications and orders were reviewed for (1) resident orders matched medications being administered and documentation is complete. (8) staff files were reviewed. Files were organized and contained current training documentation, including First Aid/CPR. Annual staff training is completed in January. RCFE Administrator certificates are pending renewal. LPA obtained a current copy of current liability insurance and LIC308. LIC500 to be emailed by 3/14/25. There were no deficiencies observed. Exit interview. Copy of report provided. |