Routine inspection·May 23, 2023

At 08:40am Licensing Program Analyst (LPA), Angela Panushkina and Licensing Program Manager (LPM) Nichelle Gillyard, conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by the staff, Sairakul Bolosheva who granted access to the facility. Administrator was present and team explained the reason for the visit. Team was informed that the facility currently has four (4) residents, of which three (3) resident are non-ambulatory and one (1) bedridden. Two residents are on hospice and 2 are receiving Home Health. Facility is approved for 1 hospice however has 2 hospice residents. Resident Files: At 8:55am team conducted resident and staff records review. The following was observed. Four(4) out of 4 resident file were either not available and or incomplete. Files were missing signed and completed Admissions agreements, physician’s reports, resident preplacement appraisals/resident reappraisal, List of personal property, ID Emergency Sheets, and personal rights. Resident appraisals that were in the file did not have services explained and were missing signatured from the resident, and or responsible party. Please see LIC858 included with this report. Hospice and Home Health files are missing and or incomplete missing care plan, admissions, notes. Staff Files: The following was observed. There are 2 staff working for at least a month without fingerprint clearance and or association to the facility. The Administrator has not renewed her Administrators Certificate since 08-26-2020. There are no completed personnel records for all 3 staff members which include the administrator. All files were missing personnel records(LIC501), Health Screening/TB results (LIC503), Criminal Record Statements (LIC508), Documented medications and general training not completed. Please see LIC859 included with this report. At approximately, 9:35am team conducted a tour of the facility, and the following was observed: Continue on LIC809-C Kitchen: T eam observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. Residents regular cycled medications was centrally stored in a cabinet in the kitchen. The medications were maintained closed by a mechanism which an individual can easily open. Team observed medication stored in the refrigerator belonging to previous resident, by the eggs. Medication was unlocked and accessible to residents. All knives and sharps in the kitchen drawer were kept unlocked and accessible to residents in care. In addition, Team observed Clorox along with other chemicals and detergents under the kitchen sink were kept unlocked and accessible to residents. There is a fire extinguisher by the kitchen and LPA was unable to verify the service/purchase date, however, the arrow on a meter was still on a green area, indicating that it was fully charged. Smoke alarm is operational however the carbon monoxide detector is inoperable. Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms have appropriate bedding and linens. Team observed two (2) half rail beds in room #1, One (1) half rail beds in room #2 and one (1) full bed rail bed in room #3. Physician's order for half/full bed rails were not available upon request. In addition, auditory alarm in bedroom #1 (exit door) was missing. Team also observed a folding bed (for the night shift staff) in the sunroom, by the exit door. LPA observed walls to be poorly scraped up in rooms 2/3 and paint around the door jamb is peeling away. Bathrooms: At 10:15am team observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured at 122.6°F. LPA team observed appropriate grab bar and non-skid mat. Team also observed appropriate hand washing signs posted in each bathroom. Common Areas : The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. No obstructions observed throughout the facility. The facility license was not posted and or available for review. Personal Rights was not posted. Outside areas: At approximately, 10:00am team toured the outside area of the facility. LPA team observed a clean covered patio and backyard furniture to accommodate the six (6) residents . Laundry: Laundry room is located outside and during the walk though, LPA team observed the room was kept unlocked and accessible to residents in care. Cleaning supplies were not locked. Continue on LIC809-C Medications review: At approximately, 10:26 am team conducted a review of medication for residents in care. None of the 4 residents had a completed centrally stored medication and destruction record. Medications for R3 were observed to be pre-poured in a in a pill box for 3 days. No First Aid Kit available for review.. Administrative: Annual fees are past due. Last notice was mailed 01-04-2023 due by 03-18-2023. Amount of $742 is due immediately. The Administrator is required to submit liability insurance, LIC500 Personnel Report . Infection control plan is due immediately. Plans were due June 2022. LPM informed the Administrator that a meeting will be requested in the near future to discuss the reason for continued non-compliance. LPA discuss the matter of a complaint in which the Administrator is running and unlicensed. Deficiencies and civil penalty issued, see LIC809Ds. Exit interview conducted, appeal rights explained and copy of report signed and delivered.