Routine inspection·July 27, 2024

On 07/27/2024 at 09:14 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four (4) residents present. Licensee/Administrator Jennifer Hahn was contacted and informed of the visit. Licensee/Administrator Hahn arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Hahn. The facility is a six (6) bedroom, four (4) bathroom home with a kitchen/dining area, living room, activity room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be bedridden. The facility has six (6) Hospice Waiver. The current census is four (4) residents. LPA Brown was accompanied by Staff #2 (S2) and Licensee/Administrator Hahn to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant : The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit (F). LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. During the tour of the facility, LPA Brown observed Resident #2 (R2), has half bed rails. Licensee/Administrator Hahn reported to LPA Brown that R2 does not have written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C *** LPA Brown observed sufficient furniture and lighting throughout the facility. Night lights were observed in the common hallway towards the residents' shared bathrooms. LPA Brown measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, and the Emergency Disaster plan, Labor Laws were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked. First Aid KIt and First Aid Guide/Book were also observed at the facility Food Service : Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision : The facility has an administrator present during the visit. However, during the staff interview, two (2) of two (2) staff interviewed reported no staff works at night, awake and on duty as required for facility with dementia residents. Deficiency will be issued. Record Review : LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals and needs and services plans. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that files reviewed were complete. During the medication audit, LPA Brown observed two (2) medications of Resident #2 (R2) were not given according to physician's directions as evidenced of discrepancy observed on the quantity of R2's two (2) medications. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to Licensee/Administrator Jennifer Hahn.