Routine inspection·April 16, 2024

At 9:45 a.m. on 04/16/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Leizl DeLaCerra conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. LPAS and staff toured the facility inside and out at 9:50 a.m. The facility was last visited on 01/11/2023 for a complaint visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for three (03). LPAs observed a maintained front yard with exercise equipment available. At the main entrance, LPAs observed postings for emergency contacts, confidential complaint contacts, Ombudsman contacts, personal rights, theft and loss policy, administrator certificate, facility sketch with evacuation routes posted, visitation policy, non-discrimination notice, activity schedule, and COVID postings. LPAs observed a screening station with digital thermometer, visitor log, sanitizer, masks, and additional PPE. Hallways had night lights. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:00 a.m. LPAs measured the room temperature to be 76 degrees Fahrenheit. Three (03) residents were engaged in activities at the dining table. The living room contained activities, exercise equipment, television, and reading material. A fireplace was appropriately covered. The facility has four (04) bedrooms. Bedroom #1 and Bedroom #2 are shared. Bedroom #3 and Bedroom #4 are private. All bedrooms contained a chair, lamp, nightstand, storage, fall prevention mats, and a bed with adequate bedding. All furnishings were clean and in good condition. A Hoyer lift was observed in Bedroom #1. The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, bidets, commodes, and a non-skid surface in the shower. At approximately 10:45 a.m. LPAs measured the water temperature to be 105.1 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods and emergency supplies of food. The stove hood needs to be cleaned and is addressed on a Technical Advisory notice. Appliances were in good condition. At 10:15 a.m. the refrigerator and freezer temperatures were measured at 33 and 0 degrees Fahrenheit, respectively. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked in a cabinet in the kitchen. A washing machine and dryer were located in the kitchen. Both were in working order. All emergency exit paths were free from obstructions. The exit gates was unlocked with a self-closing latch. Auditory alarms were turned on and functioning. At 10:20 a.m. LPAs called the functioning house phone. At approximately 10:25 a.m. smoke and carbon monoxide detectors were tested and operational. At approximately 10:30 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 08/11/2023. Fire sprinklers were observed throughout the facility. Surveillance cameras were present in common areas and the exterior. Ramps were stable with secure handrails. The garage was locked and contained cleaners, chemicals, emergency water, and an additional refrigerator. At 11:30 a.m. LPAs reviewed resident and personnel files. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.