Routine inspection·May 9, 2024

Licensing Program Analyst (LPA) Bethany Mirlohi and representative from Board of Vocational Nursing and Physiatric Technicians arrived unannounced to conduct an annual inspection. LPA met with Administrator Maria Custura during today's inspection. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured resident rooms, 1 staff room, 3 bathrooms, kitchen, common living spaces, backyard and the garage area. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. Water temperature was measured at 118 degrees. LPA reviewed 2 of 5 resident files and 2 staff files. LPA reviewed medications of two residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance. Deficiencies cited on 809-D. Exit interview conducted. Appeal rights provided.