Routine inspection·April 30, 2024

At 12:35 p.m. on 04/30/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. LPA and staff contacted the administrator at approximately 1:00 p.m. and disclosed the reason for the visit. LPA and S1 toured the facility inside and out. The facility was last visited on 03/22/2024 for a complaint visit. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06). The front yard was well maintained and free of hazards. At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, family councils, neighborhood complaint procedures, theft and loss policy, visitation policy, non-discrimination notice, facility sketch and license, confidential complaint contacts, ombudsman contacts, and administrator certificate. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:50 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Puzzles, board games, and exercise equipment were observed in the living room. Surveillance cameras monitored common areas. Three (03) out of three (03) auditory alarms were tested and functioning. At approximately 12:55 p.m. two (02) out of four (04) smoke and carbon monoxide detectors were tested and operational. Two (02) smoke alarms were removed. S1 showed LPA two (02) new smoke alarms were purchased due to the old detectors malfunctioning. The facility has three (03) bathrooms. One (01) bathroom is private, and two (02) are shared. All bathrooms 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. At approximately 12:58 p.m. and 1:03 p.m. LPA measured the water temperatures in the bathrooms near the main entrance to be 135.1 degrees Fahrenheit and 136.3 degrees Fahrenheit. This deficiency is addressed on the LIC 809-D page. The facility has four (04) bedrooms. Two (02) bedrooms are private and two (02) are shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All hospital beds had locked, secured wheels. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator and pantry. The stove hood was clean. Appliances were in good condition. At approximately 1:15 p.m. LPA observed a fully charged fire extinguisher near the stove. A receipt was attached from 04/20/2020. LPA discussed this deficiency with the administrator at approximately 2:00 p.m. The deficiency is cited on the LIC 809-D page. Sharps were locked below the counter. Cleaning solutions were locked in a closet near the kitchen. Medications and a complete first aid kit were locked above the washer and dryer. The washing machine and dryer were located in the kitchen. Both were out of order. S1 stated the facility is seeking repairs for the machines and performing resident laundry at a local laundromat in the meantime. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. The wind had knocked down the large retractable umbrella. Ramps leading out were secure. The emergency exit path was free from obstructions. Exit gates were unlocked. At approximately 1:45 p.m. LPA conducted a record review of resident and personnel files. S1’s tuberculosis test and updated CPR and First Aid certificates were not available for audit. Resident #1 (R1) and Resident #2 (R2) had diagnoses of dementia on their medical assessments. Their most recent medical assessments were older than 12 months. These deficiencies were cited on the LIC 809-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided.