Routine inspection·April 15, 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 Patricia Hounsell 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 at hand washing stations (residents use cloth hand towels which are single-use), 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 111.3 degrees. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed a knife block in the kitchen which contained numerous knives which could be a danger to residents. Deficiency cited. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. The facility has an in-ground pool which LPA Colvin observed to be gated and locked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed that though the facility has residents with Dementia, they do not have auditory alarms on the exit doors. 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 2 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 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 6 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) is diagnosed with Dementia, and therefore needs to have a Physician’s Report completed annually, but R1's last Physician's report is from 2022. Deficiency cited. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen as well as in the office and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. 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. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file. LPA Colvin inquired about quarterly emergency disaster drills, and staff stated that they conduct the drills, but they do not document them. LPA Colvin will be issuing a Technical Violation instead of a deficiency. LPA Colvin advised facility staff to start documenting the drills. An exit interview was conducted with Administrator/Licensee Patricia Hounsell and a copy of this report, LIC809D, LIC9102 TV, LIC9098 Proof of Corrections, and appeal rights were provided.