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 staff Formin "Chris" Cornista and informed him of the purpose of today's inspection. Below is a summary of what was observed: 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 121.8 degrees in building 8536 and 120.2 degrees in building 8548. Deficiency cited. . LPA Colvin tested 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. 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 numerous areas of the facility's backyard which had discarded/unused furniture, including multiple mattress and box springs. Deficiency cited. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 12 ambulatory residents, two of which may be non-ambulatory. Staffing & Staff Records: LPA Colvin observed that upon arrival at the facility, there was no staff present in the 8548 building, though there were residents present in that building. Staff for that building did not arrive until 2:48pm, and even then they spent the majority of the inspection in the staffed 8536 building. Deficiency cited. Lack of supervision is considered a serious deficiency which results in an immediate civil penalty of $500 , which LPA Colvin will be assessing today. LPA Colvin was unable to review the Administrator's file as staff could not locate it. Deficiency cited. LPA Colvin observed that both staff files reviewed (S1 & S2) did not have training included in the file. Deficiency cited. Additionally, S1's CPR/First Aid Certification was expired and there was no certification in S2's file. Deficiency cited. Resident Records: LPA Colvin reviewed the files for 5 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 One (R1) did not have an Admissions Agreement in their file, and R3's Admissions Agreement is for a different licensed facility at an entirely different location (owned by same Licensee). Deficiency cited. LPA Colvin observed that R2 & R4 both have Physician's Reports for other facilities and are over 1 year old from date of Admission. Deficiency cited. Incidental Medical Services: LPA Colvin observed that resident medication is locked in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Due to time constraints, the annual will be continued on a later date. Observations were documented and will be addressed during the annual continuation. An exit interview was conducted with staff Formin "Chris" Cornista and a copy of this report, LIC809D, LIC421IM, LIC9098 Proof of Corrections, and appeal rights were provided