Routine inspection·January 4, 2022

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Nieves and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications for each resident. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident and 2 staff files, including criminal record clearances. During the resident files review LPA observed that R1 had a fall on 1/2/2022 further investigation determined that R1 had a visit to the ER on 11/3/2021 for a foot injury, this was not reported to the department. The facility is also out of compliance with service plans for 3 of 6 files reviewed. Fire drill was completed on 6/24/2021. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. There is continued issues with deficiencies, therefore this facility will be referred to technically support. Exit interview conducted