Routine inspection·August 7, 2024

At 9:00 a.m. on 08/07/2024, Licensing Program Analysts (LPA) Nicholas Reed and Abeye Duguma conducted an unannounced annual visit. LPAs met with Staff #1 (S1) and disclosed the reason for the visit. LPAs and S1 toured the facility inside and out. A file review was conducted prior to today’s visit. The facility was last visited on 07/24/2024 for a case management visit. It is a two story building with private and shared bedrooms, private and public bathrooms, common areas, activity room, living rooms on both floors, dining room, laundry areas on both floors, and outdoor areas. It has an approved fire clearance for thirty (30) ambulatory residents and sixty (60) nonambulatory residents, of which fifteen (15) may be bedridden. Approved hospice waivers for thirty (30) residents. Upon entry, LPAs observed signs for COVID precautions, visitation policy, emergency disaster plan, Ombudsman contacts, confidential complaint contacts, theft and loss policy, house rules, resident rights, rights of resident councils, facility sketch with evacuation routes, menus, activity schedules, emergency contacts, and nondiscrimination policy. The lobby area was clean and contained appropriate seating. LPAs observed residents in the television room near the main entrance engaged in the morning activity routine with the Activity Director. The television room contained furniture in good repair, a piano, and a television. The outdoor area was accessible from the television room. The outdoor area contained patio furniture in good repair and was shaded by umbrellas. At approximately 10:05 a.m. LPAs observed a fully charged fire extinguisher near the lobby. It was last serviced on 02/21/2024. The medication room was inaccessible to persons in care. The medication room contained a complete first aid kit, a medication refrigerator, a locked medication cart, a separate refrigerator for snacks and drinks, and disposal bins for sharps. The activity room contained music, art supplies, board games, and exercise equipment. Cameras were observed in hallways and common areas. Public restrooms were clean and fully stocked with liquid soap, paper towels, and trash cans with tight fitting lids. The janitorial closet, storage rooms, and employee lounge were locked and inaccessible. A linen closet was also observed in the hallways and contained an adequate supply of fresh sheets and beddings. Bedrooms were sanitary and free of hazards. Resident bathrooms and showers contained sturdy grab bars, commodes, liquid soap, personal towels, and non-skid mats. Resident rooms contained chairs, nightstands, lamps, call systems, and beds with furnishings in good condition. “No smoking – Oxygen in use” signs were observed in appropriate rooms. LPAs observed an adequate supply of perishable and non-perishable foods in the kitchen. A daily menu and an alternate menu were posted in the dining room. Modified diet cards were posted. Emergency water and food supplies were observed in separate store rooms. The hood was last cleaned and certified on 07/05/24. Sharps and cleaning solutions were locked and stored separately from food supplies. At 10:30 a.m. the walk-in refrigerator temperature was measured to be 32 degrees Fahrenheit. The walk-in freezer temperature was measured to be 10 degrees Fahrenheit at 10:30 a.m. and 0 degrees Fahrenheit at 3:00 p.m. S1 explained that the high volume of use during meal preparation hours attributes to an increased temperature. No food was observed to be spoiled or unsafe. A deficiency is cited on the corresponding LIC 809-D page for the freezer being above the regulatory temperature. The house telephone was tested around 10:45 a.m. and deemed operational. The laundry room was located behind the activity room. It contained 4 operable machines. An additional laundry area was located upstairs for residents to use. Detergents were locked and inaccessible. Fire sprinklers, alarms, and extinguishers were located throughout the facility. LPAs also observed a designated smoking area upstairs with appropriate signage, air filters, and plants. At approximately 11:15 a.m. a carbon monoxide detector was tested and operational. At approximately 11:30 a.m. and 11:40 a.m., pull cords in Rooms 211 and 103 were tested and deemed operational. Water temperatures were measured to be 109.5 and 113.1 degrees Fahrenheit. Outside, LPAs observed a gardening area and a designated smoking area. Around 11:45 a.m. S1 stated a vehicle recently crashed into a perimeter wall, so the facility placed objects around the broken wall area to maintain resident safety. Three (03) out of three (03) emergency exits were unlocked, and all emergency exit paths were free of hazards. Emergency chairs were observed in two (02) out of (02) stairwells. LPAs conducted a record review at approximately 12:00 p.m. of resident and personnel files. All required documents were up to date and readily available for inspection. Recent fire tests and drills and updated liability insurance were also reviewed. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.