Physical Premise: The facility appears to be clean and well maintained. Resident bedrooms appear personalized and furnishings appear appropriate to meet the needs of the residents. There is a record of monthly fire training/drills and emergency equipment has been serviced with in the last year. Hazardous products are secured. There is 72.0 hours of emergency supplies available in the event of a disaster. There is a list of the supplies that are available and they are checked every 3 months regarding expired products.
Policies and Procedures: As any policies and procedures revised within the last year have been reviewed at a sister facility, they were not reviewed at the time of this inspection.
Staff Records: The facility's computer program has a record of documentation held on file a the main office. In review, it appears all required documentation is available.
Resident Records: In review of documentation for 1 resident the following is noted to available.
· TB/immunization status
· monthly weight
· Dental professional visit(s)
· Consent for contact Dr. and/or call 911 is in progress
· Consent for release.
· Rep agreement
Care/Supervision: In review of documentation for one resident, it includes the following, appears to be detailed, appropriate and has recently been reviewed.
· Care plan
· Oral care plan
· Nutritional assessment
· Nutrition care plan.
· Recreation/activity care plan (very detailed)
· Schedule of activities
· Financial Records
· Quarterly reviews
Nutrition: The following is noted:
· A Substitution list is available for each resident in the event they do not eat as per the menu.
Please review the menu for each day/meal and snack as it appears there may be a couple of snacks that do not have 2 food groups.
· Food is appropriately stored including dates of opening & or repackaging group
· (ie frozen
· Meals and more audits are in process.
Medication:
· Medications are secured and appear to be stored appropriately.
The pharmacist has inspected within the last year and the MSAC minutes are available for review.
· There does not appear to by any expired medications
· Effect of PRN’s are documented
· Mars are maintained
· There are regular med reviews.
CCFL would like to thank you for your time and assistance during the process of this inspection.
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