Routine inspection·December 20, 2022

On 12/20/2022 at 9:47 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Staff #1 (S1) who was wearing a mask and granted access. S1 took LPAs temperature and asked LPA to sign in. S1 called another staff Joselito Bishasa to continue assisting LPA. LPA asked Joselito to call administrator JoJo Cajayon. Jojo called Joselito and LPA explained the reason for the visit and asked if he would be joining us. Jojo was an hour away and designated Joselito to sign today's report. The inspection tool was used to complete the visit. At 10:06 a.m. LPA began a physical plant tour of the facility and the following was observed: Infection Control: LPA observed appropriate infection control signs posted in front of the door. Upon entry three out of three staff were wearing masks. LPA observed appropriate signs along the entry and hand washing signs in two out of two bathrooms. Trash cans with tight fitting lids were observed in the kitchen, bathrooms and resident rooms. Joselito states the facility has enough PPE for 30 days. Dining / Living Area: The dining and living area were well lit, clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area is not in use. In the hallway by the dining area LPA observed the thermostat at a comfortable temperature of 76°F. The fire extinguisher was observed by the dining table and was last serviced on 04/29/2022. Dining table was clean and clear clutter. Furniture appeared to be clean and in good repair. Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Cleaning solutions are locked under the sink. Knives are kept locked in a kitchen drawer inaccessible to residents. LPA observed a 2-day perishable and 7-day non-perishable supply of food. Bedrooms: There are six (6) bedrooms designated for resident use. One (1) out of the six (6) rooms is being occupied by staff labeled 2. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens. At 10:23 a.m. LPA observed a large chair with linings on it obstructing an exit door in a resident room labeled 3. LPA asked Joselito about the chair obstructing the exit door. Joselito removed the chair from the bedroom immediately. LPA observed full length bed rails in resident's bedroom labeled 1, 3 and 5 and half bed rails in resident bedrooms labeled 4 and 6. LPA asked Joselito if any resident was in hospice care and if they had doctor orders for the bed rails. Joseilto was not sure if they had orders in resident files. Joselito called the administrator Jojo and the administrator confirmed no resident was on hospice and he would have to look at resident files to check if residents had bed rail orders. LPA advised administrator they would be reviewing resident files. LPA observed smoke alarms through out the facility that are interconnected and dual carbon monoxide. At 10:26 a.m. all smoke alarms were tested and functioned properly. Bathrooms : There are two (2) bathrooms designated for resident use. Both bathrooms are accessible to residents by the halllway. Both bathrooms were well lit, clean, had grab bars, had hand washing signs, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 10:28 a.m. water temperature in two out of the two bathrooms was tested at 119.7 degrees Fahrenheit. Surrounding Grounds : There were no visible hazards, and passageways were free from obstruction. Side gate was observed closed but unlocked. There is appropriate outdoor seating for residents with no shade. LPA observed one shed in the backyard. Shed is being used for storage. Medications/ Resident file: LPA observed, resident medications locked in a small kitchen refrigerator and looked in a hallway cabinet inaccessible to residents. At 11:30 am LPA reviewed five out of five resident files. LPA observed half bed rail orders for one out of five resident files. Deficiencies cited (refer to 809D). Exit interview conducted. Appeal rights provided. Copy of report provided.