Routine inspection·June 28, 2023

Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. A tour of the facility was conducted with the Administrator. The residence was set at 74 F temperature and free of passageway obstructions inside and outside. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication room. Cleaning supplies were in a locked closet. Smoke detectors and carbon monoxide detectors were checked and operating. Smoke detectors are hard wired with a fire panel and pull station fire alarm. Facility has a fire sprinkler system. Fire extinguishers were charged and had service dates of 05/06/23. There was outdoor seating for the residents. Resident, medication and staff records were reviewed. Current first aid and CPR were reviewed.. See LIC809C for continuance. Due to time constraints deficiencies are listed below and citations will be issued at a later date. LPAs will return to the facility at a later date or an appointment at the Regional Office will be scheduled. Licensee/Administrator. LPAs observed the following deficiencies: Medication errors, medication storage, medication logs, no staff training in all areas, inadequate staffing, no plan of operation, no dementia plan in plan of operation, trash cans without lids, strong urine odor, no restricted health care plans, staff administering injections, no skid mats in shower, shared bathroom needs cleaning, pests were observed in resident bathroom and pest droppings were observed in kitchen, hot water over 125 F and under 85 F, resident records are not current/missing signatures/conflicting information, resident records are accessible in unlocked cabinet in common area, no updated physicians reports, reappraisals, needs and service plans ect., R2 has full bed rails without a doctor note, observed activities schedule but not activities were observed that were on the schedule for 06/28/23.. An exit interview was conducted with Administrator and a copy of this report was provided.