Routine inspection·October 30, 2024

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Administrator, Oliver Calceta. The facility is licensed for six (6) Non-Ambulatory Elderly residents; One (1) of whom may bedridden in bedroom #3 only. LPA, accompanied by Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents measured at 111 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. However, the medications did not appear accurate due to the facility not using a Medication Administration Record or calendar count on bubble packs. Also, the facility's Centrally Stored Medication Destruction Record was not accurate due to not having any start dates of the medication to ensure an accurate audit of medications. No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Staff did not have a required health screening or TB test results on file. Resident #1 (R1) had a change in condition, the facility did not comply with regulations. Multiple residents did not have required documentation, to include TB test results. Confidential records were stored in locked areas. Deficiencies were observed or cited during today's annual inspection. Advisory Notes were also issued. An exit interview was conducted with the Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.