Routine inspection·April 4, 2023

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/04/2023 at 09:15 am. LPA was met by Staff# 1 (S1) and explained the purpose of the visit. Facility is licensed to residents over 60 years old and is currently approved for five (5) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), and Resident Roster (LIC 9020). LPA OBSERVATIONS: Tour began at 09:42 am and was led by LPA due to no designation of facility responsibility. According to S1 Administrator Pearl He is out of the country and neither S1 nor LPA could locate LIC 308 (Designation of Facility Responsibility form). At 10:20 am, Staff #2 (S2) arrived to assist with the remaining tour. The Facility is divided into three (3) units and located in a main street. Each unit contains 2 resident bedrooms, 1 shared full resident bathroom, hand washing station, kitchen, living room, dining room, and linen closet. UNIT 940 LIVING ROOM AREA: Living room contained one (1) couch and LPA observed several chairs and a small table in this area. LPA observed files, boxes, bags filled with various items in the corner of the room. LPA observed a mattress and folding bed frame behind couch. At 12:55 pm, when LPA was returning to unit 940 to gather briefcase, LPA observed R3 sitting in a wheelchair, undressed from the waist down, in a common area. KITCHEN: Water temperature in kitchen was measured at 122.3 degrees F, which is not within the required 105 – 120 degrees F. LPA observed kitchen walls to contain yellowish and brown spatter on stove backsplash and surrounding walls. LPA observed dirt, litter, and crumbs in kitchen cabinet, that contained spices. Kitchen floors were observed to be dirty with food debris and baseboards contained grime. Kitchen appliances were observed to contain caked on spatter and were sticky to the touch. HAND WASHING STATION: Water temperature was measured at 123.0 degrees F, which is not within the required 105 – 120 degrees F. LPA observed toilet bowl disinfectant in cabinet located directly under sink, which was accessible to 2 out of 2 residents in care. LPA observed a pair of scissors in a plastic cup behind hand washing station, which was accessible to 2 clients. RESIDENT BEDROOMS 1-2: All contained the required furnishings, linen, and lighting as required. SHARED BATHROOM# 1: LPA observed toilet to be dirty with yellowish/brown stains in rim of toilet. LPA observed hair and caked dirt behind toilet seat. LPA observed grab bars near toilet and standing shower. Bathroom floors were observed to contain hair and grime. Water temperature was measure at 126.5 degrees F. Dining room: LPA observed serval bags in various items on dining room table. LPA observed two (2) chairs near table. LPA observed PPE supplies, and adult hygiene products stacked in corner of dining area. CENTRALLY STORED MEDICATIONS: LPA reviewed medications for 2 residents in this unit. UNIT 942 LIVING ROOM AREA: Living room contained one (1) couch and LPA observed several chairs and a small table in this area. LPA observed a table with various folders and papers piled up in a nearby corner. KITCHEN: Water temperature in kitchen was measured at 135.3 degrees F, which is not within the required 105 – 120 degrees F. LPA observed kitchen walls to contain yellowish and brown spatter on stove backsplash and surrounding walls. Kitchen floors were observed to be dirty with food debris and baseboards contained grime. Sufficient supply of perishables and non-perishables was observed. HAND WASHING STATION: Water temperature was measured at 140.0 degrees F, which is not within the required 105 – 120 degrees F. LPA observed a pair of scissors in a cup behind hand washing station. RESIDENT BEDROOMS 3-4: All contained the required furnishings, linen, and lighting as required. SHARED BATHROOM# 1: LPA observed toilet to be dirty with yellowish/brown stains in rim of toilet. LPA observed hair and caked dirt behind toilet seat. LPA observed grab bars near toilet and standing shower. Bathroom floors were observed to contain hair and grime. Water temperature was measured at 138.2 degrees F. DINING ROOM: LPA observed serval bags and papers located on table. Not enough seating for residents and visitors was observed. CENTRALLY STORED MEDICATIONS: LPA observed C3’s spouse access C3’s open medication cabinet that staff opened at their request. C3’s spouse began to divide medications in holders and place back in medication cabinet. UNIT 944 LIVING ROOM AREA: Living room contained one (1) couch and LPA observed several chairs and a small table in this area. LPA observed a table with various folders and papers piled up in a nearby corner. KITCHEN: Water temperature in kitchen was measured at 155.3 degrees F, which is not within the required 105 – 120 degrees F. LPA observed kitchen walls to contain yellowish and brown spatter on stove backsplash and surrounding walls. Kitchen floors were observed to be dirty with food debris and baseboards contained grime. Sufficient supply of perishables and non-perishables was observed. Disinfectant sprays were observed under kitchen sink and accessible to 2 clients in care. LPA observed stove knob to be held in place by black tape. Appliances were observed to be dirty and sticky to touch. HAND WASHING STATION: Water temperature was measured at 147.9 degrees F, which is not within the required 105 – 120 degrees F. LPA observed a pair of scissors in a cup behind hand washing station. RESIDENT BEDROOMS 5-6: All contained the required furnishings, linen, and lighting as required. SHARED BATHROOM# 1: LPA observed toilet to be dirty with yellowish/brown stains in rim of toilet. LPA observed hair and caked dirt behind toilet seat. LPA observed grab bars near toilet and standing shower. Bathroom floors were observed to contain hair and grime. Water temperature was measured at 154.5 degrees F. DINING ROOM: LPA observed serval bags and papers located on table. Not enough seating for residents and visitors was observed. LPA observed a bottle of tide laundry soap next to food items on a near by shelf. LPA observed a bottle of wound care next to bananas. CENTRALLY STORED MEDICATIONS: LPA observed R1 and R2 received medications but staff did not record dosage accurately. Deficiencies are being cited. Exit interview conducted with S2, and LIC 809, LIC 809-C, LIC 809-D, and appeals rights will be emailed due to printer problems.