Routine inspection·June 19, 2024

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the staff member. Staff member called the Administrator who stated would not be able to come to the facility until 3:00 pm. At 10:20 am, LPA Spaeth spoke to the licensee, Anne Gregorio who stated will be reporting to the facility. LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for five (5) non-ambulatory residents of which one may be bedridden. LPA confirmed there are four residents in the facility. LPA Spaeth observed another person living in the facility. The staff member confirmed the other person living there is a relative of the staff member. However, LPA observed the relative's name was not listed on the Facility Personnel Report Summary. LPA Spaeth spoke to the Licensee and stated the relative would have to leave the facility and not return until the criminal record clearance had been completed. The Licensee arrived at 11:00 am. The Administrator instructed the relative they would have to leave the facility until the clearance has been completed. LPA observed the relative left the facility at 11:15 am with the Licensee. LPA and the staff member toured the facility at 10:10 am until 10:50 am. LPA Spaeth observed the following: Kitchen - LPA Spaeth observed a two day supply of perishable food and a seven-day supply of non-perishable canned goods. At 10:20 am, LPA observed the medication cabinet was not locked. LPA instructed the caregiver to lock the cabinet. At 10:25 am, LPA observed the knives were stored in the pantry and the pantry was not locked. The staff member locked the knives in the medication cabinet. Common Areas –The living room and dining room are combined and contained comfortable seating along with dining room table and chairs. The family room contained comfortable seating and a television. Cont'd on 809-C Bathroom – The bathroom contained grab bars, slip resistant mats, paper towels and a covered trash can. The water temperature was tested at 10:45 am and was 120 degrees F. Backyard –The backyard contained comfortable seating. The gate leading from the backyard to the front yard was not locked. LPA observed a rake and shovel were located in the backyard. The caregiver locked both gardening tools in the garage. Laundry Area – The laundry room was locked and contained cleaning solutions, washer/dryer, and laundry detergent. The garage did not contain any hazardous items and the garage was locked. The staff room is located in the garage and was locked. . Egress System - At 10:55 am, LPA checked all exit doors and observed the system was not working. The Administrator called a repairman to fix the system. Smoke/Carbon Monoxide Detectors - The smoke/carbon monoxide detectors were tested at 11:10 am and were properly working. Residents’ Records -LPA reviewed residents' records at 11:20 am until 11:00 am. LPA observed R1’s file did not contain an updated Physician’s Report. Staff Records - LPA reviewed five staff records at 1:15 pm until 2:15 pm. LPA Spaeth observed S1 had not completed the required CPR/First aid training. LPA Spaeth spoke to S1 at 1:45 pm who confirmed they had not completed the training. LPA attempted to contact the Administrator via phone call at 2:00 pm to discuss the deficiencies. However, LPA was unable to reach the Administrator. Based upon LPA's observations, the following deficiencies were cited (see 809-D page). Exit interview conducted, appeal rights discussed and a copy of the report was given.