Routine inspection·June 12, 2024

On 6/12/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Bahira Hanna was present to assist with the facility inspection on today's date. The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for four (4) residents. Currently, there are one (1) Hospice resident present during today’s visit. This is a single story with a two-car garage facility. The facility has six bedrooms, two full bathrooms and one half bathroom. At around 10:30 AM, LPA conducted a tour of the physical plant accompanied by Administrator Hanna, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.2 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has one fire extinguisher which was mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the CONTINUED ON LIC 809C the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working land line phone was operational. The last fire drill was conducted on 6/7/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 2/25/2024 - 2/25/2025. A review of four residents (R1-R4) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Bahira Hanna # 7019658740 - Expiration 8/20/2025. No deficiencies during this inspection visit. An exit interview was conducted with Administrator Bahira Hanna, and a copy of the report was provided.