Routine inspection·April 17, 2026

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Lisa DiBartolo, Administrator Assistant (AA). Licensee Alex Varshavsky was also present. Licensee Administrator certificate 7019479740 expires 7/15/26. Facility currently has thirty one (31) residents in care five (5) of which are currently on hospice. LPA went over staff associated to facility with AA. Staff (S1) was found to have fingerprint clearance but not associated to the facility ( deficiency cited, see 809D ). At approximately 9:30am LPA and licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food in the kitchen was found to be stored in a safe manner with open items covered and labeled with opened dates present. Facility has a food storage room. Food storage room there are pesticides and toxins present (deficiency cited, see 809D ). All other cleaning products and laundry soaps are located in the dedicated cleaning closet or laundry room. All bedrooms were equipped with lighting. Rooms #2, #3, #15, and #17 need a chair and #11 and #12 need another chair as they are a shared room. Rooms #14, #4, #6, #9, needs a chest of drawers and #12 needs another a chest of drawers as it is a shared room ( deficiency cited, see 809D) . Shower in room #15 and room #4 need a grab bar ( deficiency cited, see 809D) . All other resident bathrooms had required bath mats and grab bars. Facility had common towels present in shared rooms and all but two (2) other resident rooms did not have paper towels present. Per licensee, facility does not keep Continued on 809C... Continued from 809... paper towels in resident rooms purposely, licensee claims residents flush them down the toilets ( deficiency cited, see 809D ). Room #!1 has a broken vanity cabinet door and room #2 has broken blinds. Internal courtyard has deck planks that do not meet, leave holes present such that one can see through to the ground, per licensee these planks were just repaired. However, wood panel just outside of room #14 leading to internal courtyard is splintered, bows and bends with pressure and has black substance present. Facility food storage room has a floor that bows and bends when pressure is applied ( deficiency cited, see 809D ). Triple antibiotic ointment with active ingredients of Bacitracin Zinc 400 units, Neomycin Sulfate 3.5mg, Polymyxin B Sulfate 5000 units was found by LPA and licensee in room #20 ( deficiency cited, see 809D ). Extra hygiene products and linens were available. Water temperature in sinks measured at 118.2 degrees F in the kitchen, 110.6 degrees F in room #20, 106.9 degrees F in the common bath/shower room, 108.2 degrees F in room #11, and 106.2 degrees F in room # 15 all of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only. Fire extinguishers were last inspected 03/18/26. Sprinklers were tested and serviced by vendor on 3/18/26 all systems pass. Smoke detectors located throughout the facility are serviced by vendor, all systems passed, last service date was 6/2/25. Carbon monoxide detector present in facility. LPA and licensee tested detector and found it functional and operational. Facility’s last quarterly disaster drill was conducted on 01/20/26. Facility has a backup generator for use during a power outage. At approximately 11:00am LPA, licensee, and Administrator Assistant conducted a spot check of medication and medication records. Medication is centrally stored in two (2) locked medication carts. The following errors were found for resident (R1): prescribed Mentol-Zinc Oxide, hydrocortisone 1% cream, and Miconazole 2% were listed on the current physician's orders but not present on the Centrally Stored Medication log (CSML) ( deficiency cited, see 809D ). Morphine 20mg was on the CSML but the wrong instructions were listed. Instructions on physician's orders were: take by mouth every hour as needed for pain or shortness of breath, but CSML listed for it be administered "2X per day" ( deficiency cited, see 809D ). Senna 8.6 mg bubble Continued on 809C(2)... Continued from 809C... pack was stared 4/2/26 to be administered on Mondays and Thursdays 1 tab 2 times per day. Total tabs in bubble pack on 4/2/26 was 31 and today 22 pills remain, so facility is under by 1 tab ( deficiency cited, see 809D ). At approximately 2:00pm LPA conducted a review of eight (8) out of thirty-one (31) resident files. R1 had a medical assessment dated 12/2024. Per AA, facility has been requesting an updated medical assessment since 3/2026. LPA reviewed documentation of requests. Request dated 4/8/26. LPA advised that request for an updated medical assessment should begin no later than the same month in which the update is due and if the facility makes an attempt to get an update be sure document the request, such a a fax transmission or copy of email. All other documentation present. No deficiencies cited. LPA and Licensee discussed Infection Control Plan. LPA and Licensee discussed Emergency Disaster Plan. AA confirmed no updates needed. LPA will return at a later date to complete annual inspection and issue citations for those items identified in today's report as well as any other deficiencies identified when LPA returns to complete annual inspection. Exit interview conducted with licensee and a copy of this report was given.