Routine inspection·April 17, 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 Zinica Clark 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, and hand washing guides posted above sinks. 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 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. 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. Knives and other sharp objects are kept in the locked garage. LPA Colvin observed Comet and Windex cleaners under the kitchen sink. The facility has residents with Dementia, and therefore these items pose a risk to the residents since they were accessible. Deficiency cited. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents. Facility has a hospice waiver for 6 residents. Planned Activities: LPA Colvin confirmed with interviews of staff and residents that the facility provides activities for residents to engage in and are tailored to their interests. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a closet and inaccessible to residents. LPA Colvin observed that the facility has a Medication Administration Log (MAR) for each resident, but they are not tracking the doses of medication administered. The facility is not required to use a MAR log, but LPA Colvin is issuing a Technical Advisory Note to suggest that the facility either fully use the log, or to not use it at all. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. 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 reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. LPA Colvin observed that one staff member (S1) has expired CPR/First Aid Certification. Deficiency cited. 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 R1's file does not contain a completed Needs and Services Plan. Deficiency cited. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and the facility staff are conducting drills quarterly. An exit interview was conducted with Administrator/Licensee Zinica Clark and a copy of this report, LIC809Ds, LIC9102 TV, LIC9098 Proof of Corrections, and appeal rights were provided.