Correction check·November 15, 2023

On 11/15/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Plan of Correction (POC) and was met by assistant administrator Kian Pascual. The purpose of the visit is to follow-up on the POC that was due on 10/26/23. The facility requested for an extension and was granted with a new POC date of 11/05/23. On 10/05/23, an annual visit was conducted and facility was cited for: DEFICIENCIES: 8 7 608(5)(B) Postural Support: non-authorized full bed rails for resident #3 – Type B (corrected 11/15/23 ) 87309(a)(1) Disinfectants/Toxic Cleaning Solutions: unsecured/unlocked bathroom #2 cabinet – Type A (corrected) 87303(a) Room #3 window blinds: Broken shades – Type B (corrected) 87303(a) Room #4 End Table missing drawer – Type B (corrected) Administrators Certificate: Expired for Staff #1 – Type B (not cleared) 87411(c)(1) No current CPR/First Aid certificates - staff #1 and #5 - Type B (corrected) 87705(5)) Resident 4: No current medical and appraisal assessment for resident with Dementia – Type (not cleared) 87309(b) Medicines required refrigeration not stored properly - Type A (corrected) 87415(a) No night supervision - No night shift staff after 8pm - Type B (corrected 11/15/23 ) 1569.695(c) No quarterly emergency drills conducted/documented - Type B (not cleared) 87465(d) No documentation/record keeping of PRN for resident #4 - Type B (corrected 11/15/23) 87465(d)(3) Prescribed medications and PRN not included in (MAR) - Type B (corrected 11/15/23 ) 87405(b)(2) Administrator's Qualification: Failed to conform to applicable rules and regulations, which resulted to multiple citations. - Type B (not cleared) The licensee is being cited civil penalties for violations that have not been cleared as of 11/15/23. An exit interview conducted with Kian Pascual and a copy of the report is provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *