Routine inspection·August 29, 2022

At 10:30 a.m. on 08/29/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out. The facility was last visited on 06/15/2022 for a complaint visit. It is a single story building with 4 bedrooms, 2 bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatiory residents, of which 1 may be bedridden in Bedroom #1. The facility serves residents with dementia. Approved hospice waivers for 2. The facility uses surveillance cameras on the interior and exterior. On the front door hung a sign regarding the facility’s visitation policy. LPA was not screened for infectious disease upon entry. The screening station contained digital thermometer, masks, hand sanitizer, and visitor log. The facility did not track temperature, symptoms, and vaccination statuses of all visitors. Facility postings included Emergency Disaster Plan, facility license, administrator certificate, facility sketch, confidential complaints contact, personal rights, and COVID policies and precautions. The facility has 4 bedrooms. 2 are private. 2 are shared. All bedrooms contained a nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. At approximately 10:57 a.m. staff confirmed that the resident in Bedroom #1 had passed away about one month ago. Bedrooms #2 and #4 are shared rooms. In both bedrooms, the beds were less than 6 feet apart and did not provide social distance for residents. In Bedroom #3 and Bedroom #4, all 3 residents were observed in bed with full bed rails. The facility has 2 bathrooms. The bathroom designated for residents contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. A closet in the hallway contained a sufficient supply of fresh linens. LPA observed an adequate supply of perishable and non-perishable food in the kitchen. Appliances were functional and clean. Sharps were locked below the counter, and cleaning solutions were locked in the laundry room. A washer and dryer in good condition were also located in the laundry room. Medications were locked near the dining room. A fully charged fire extinguisher hung near the kitchen. Walls, floors, ceilings, windows, and blinds were clean and in good repair. At 10:58 a.m. LPA tested the dual-function smoke and carbon monoxide detector to be operational. 2 out of 2 detectors functioned during the test, and an additional verbal alert sounded. At 11:00 a.m. LPA measured the room temperature to be 78 degrees Fahrenheit. LPA observed a covered patio area outside with furniture in good repair. The emergency exit was unlocked with an inward facing latch. Emergency exit paths were free from debris. At approximately 11:30 a.m. LPA conducted a facility file review. No death report was sent for the resident in Bedroom #1. Furthermore, the staff working was not associated to the facility and could not recall obtaining a criminal background clearance. An interview at 11:35 a.m. with staff and residents confirmed that the 3 residents in Bedrooms #3 and #4 are receiving hospice services, and one resident in Bedroom #4 is bedridden. LPA cited the deficiencies on the LIC 809-D page. Exit interview conducted. Copy of report, appeal rights, and citations issued.