Routine inspection·April 19, 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 Verly Frias and informed him 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 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 109.5 degrees. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed multiple chemicals in the cabinet under the sink, which was unlocked. Deficiency cited. 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 are kept locked up and away from resident reach. Operational Requirements: The facility has a licensed capacity of 6 non-ambulatory residents. Facility has a hospice waiver for 2 residents. LPA Colvin observed that Resident One (R1) is bedridden, and the facility does not have bedridden fire clearance. Deficiency cited. Violations of a facility's fire clearance result in an immediate civil penalty of $500 , which LPA Colvin will be assessing today. LPA Colvin additionally notes that she cited the facility for the same violation on 8/27/21 during a Case Management Visit. P art of the Plan of Correction was that the Licensee/Administrator submitted a Statement of Understanding that they are not permitted to accept or retain bedridden residents without proper fire clearance. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. L PA Colvin additionally confirmed that the facility has an Administrator present at the facility. LPA Colvin observed that the Administrator's Administrator Certificate expired 4/10/24. LPA Colvin was not able to verify the submission of a renewal with the Administrator Certification Branch, but the Licensee/Administrator was able to provide LPA Colvin with a Certified Mail Return Receipt dated 2/13/24 and addressed to the Administrator Certification Branch. L PA 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 2 of 3 residents (R2 & R3) do not have a completed Needs & Services Plan in their file. Deficiency cited. LPA Colvin observed that R2 does not have a Pre-Admission Appraisal in their file. Deficiency cited. LPA Colvin observed that R3's Admissions Agreement is missing most of the important information, such as facility information, rate for services, and services provided. Deficiency cited. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Planned Activities: LPA Colvin confirmed that the facility provides activities for residents to engage in. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file, but is not conducting quarterly emergency disaster drills, which are to be done quarterly. Deficiency cited . Other: LPA Colvin observed that the facility has outstanding unpaid licensing fees in the amount of $989. Deficiency cited An exit interview was conducted with Administrator/Licensee Verly Frias and a copy of this report, LIC809D, LIC421IM, and appeal rights were provided.