Routine inspection·March 18, 2024

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Lorena Alandy and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and tight-fitting lids on trash cans. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 118.9 degrees in the master bathroom and 124.1 degrees in the hallway bathroom. Deficiency cited. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked away from residents' reach in a drawer in the kitchen. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed cameras in the common areas of the facility, which are not included in the facility's Plan of Operation. Deficiency cited. LPA Colvin informed Administrator/Licensee of items that needed to be addressed in the updated Plan of Operator for the use of cameras, as well as them needing to add a consent form to their Admissions Agreement. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 6 residents. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin learned while at the facility that the Administrator recently returned from a six-month trip out of the country. Licensing was not notified of the absence of the Administrator and advised on who would be present to oversee the facility during this time. Deficiency cited. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. Resident Records: LPA Colvin reviewed the files for all 3 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that Resident 1 (R1) was admitted to the facility in September 2023 but does not have a Physician's Report on File. Deficiency cited. LPA Colvin additionally observed that R1's Needs & Services Plan is incomplete, as it merely states likes/dislikes of the resident, as well as their diagnosis, but does not indicate what they need from the facility or how staff will meet that need. Deficiency cited. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. LPA Colvin observed that R1 does not have an updated Centrally Stored Medication Log, and the one on file with the facility does not have R1's most recently prescribed medications. Deficiency cited. Planned Activities: LPA Colvin observed the facility's Activity Calendar as well as residents engaging in their own private activities in their rooms. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file, though their last disaster drill was conducted in July 2023. Deficiency cited . An exit interview was conducted with Administrator/Licensee Lorena Alandy and a copy of this report, LIC809D, LIC9098 Proof of Corrections, and appeal rights were provided.