Routine inspection·February 28, 2022

Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility on 02/28/2022 at 2:46pm to conducted a One (1)year Required Infection Control visit. LPA meet with staff Luzzy Dugoy and explained the purpose of this visit. A tour of the physical plant was conducted at 2:51pm and the following was observed: At the time of the inspection, the facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) posted. The PPE screening station is located in the living room area on a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. One (01) hospice resident and waiver for (01). The facility has an approved mitigation plan on file. Kitchen: At 2:54pm LPA observed an adequate supply of perishables and non-perishable food located in the fridge and freezer. The Fire Extinguisher located on the wall next to the exit door which has a service tag dated 03/31/2021. LPA observed sharps to be locked and stored in a cabinet near the exit door to the back of the kitchen. LPA observed toxins, cleaning solutions, and soap stored and locked underneath the kitchen cabinet sink. At 3:08pm the fire alarm system was tested and observed to be working, it is hard wired and interconnected. The carbon monoxide detector is located on the wall in the kitchen. Appliances observed to be in good repair and operational. LPA observed fresh Storage Rooms: LPA observed a storage room at 3:17pm located in the kitchen near the exit door, to be storing dry/hot cereal, can goods(soups, chili, beans, sauces, etc), snacks, paper towels and forks/spoons. Bedrooms: The facility has four (04) bedrooms, which one is designated as staff room to be storing boxes of personal items. At 3:25pm LPA observed all bedrooms to be clean and clear from obstruction, properly furnished, sufficient lighting, appropriate bedding and linens. Trash cans observed to have attached lid. (Continued on LIC 809C) Bathrooms: At 3:31pm LPA observed the bathrooms to be clean and in good repair. LPA observed the appropriate grab bars in and around the toilet and shower also non-skid mats are located in the shower area. The water temperature measured 110.8 between 112.2 degrees Fahrenheit. Hand towels and wash clothes are not shared Living, dining room and common areas: Observed to be appropriately furnished with tables and chairs and adequate lighting. The facility maintains a comfortable temperature at 77 degree Fahrenheit. Observed to be clean and in good repair. Medications: At 3:42 pm LPA observed the medication cupboard locked and stored near the bathroom and living room. The facility first aid kit and manual located on top of the medication cupboard. LPA observed extra towels and linens stored on shelves mounted into the wall next to the medication cupboard. Backyard: At 3:48 LPA observed the backyard and surrounding area of the facility to be clean and clear from debris. A covered canopy area with tables and chairs for lounging, the front porch area is shaded with chairs for lounging. A detached garage observed to be locked and storing PPE, incontinent supplies, and personal items inaccessible to residents. No bodies of water observed on the premises. Laundry Room: LPA observed the washing machines located outside in the back of the facility at 3:51pm observed to be clean and clear from obstruction. Laundry soap, toxins and cleaning supplies are stored outside on a shelf near the laundry machines, inaccessible to residents.