Routine inspection (multi-day)·December 3, 2024

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to continue the annual inspection that was started on 11/22/2024. The LPA met with Administrator, Emely Rodriguez, and informed her of the purpose for the visit. Physical Plant: The facility consists of Twelve (12) resident bedrooms, thirteen (13) bathrooms, one (1) laundry room, a kitchen and dinning area, a living room area, a medication room and office, a staff work station and a yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Rodriguez, no weapons are stored at the facility. The facility is being maintained at a comfortable temperature. All indoor passageways were kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet and shower used by residents. Resident showers have non-skid mats present. The hot water temperature was tested and observed to be within regulatory requirements. One carbon monoxide device was tested by staff and was observed to be in operating condition. The facility's smoke alarm panel was observed to show the system was in normal operation. The facility was kept clean, organized and free of any odors. The LPA observed a chain and lock on the only emergency exit in the back yard area of the facility. An interview with the local fire department revealed the chain and lock should not have been placed on the exit gate. A citation and civil penalty will be issued. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care and medication training was observed on file. No postural support training or restricted health training was observed on file for Staff One (S1) or Two (S2). Insufficient hours for hospice training were observed on file for S1 and S2. A citation will be issued. Resident files had admission agreements, medical assessments, appraisal/needs and services plans, and other required records on file. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for ten (10) residents and there are currently five (5) residents in care receiving hospice services. There is a disaster and mass casualty plan in place. Proof of emergency drills was observed on file. According to Administrator Rodriguez, the corporation is currently active. The LPA observed current liability insurance on file. Medication Review: The LPA inspected resident medications. Medications were observed to be well organize and inaccessible to unauthorized individuals. Centrally stored medication destruction records were observed on file. Administrator Rodrgiuez reported an updated admission agreement was established by the licensee and she agreed to provide the LPA with a copy for department review. She also agreed to provide the LPA with a copy of the current liability insurance, staff schedule, and resident roster. An exit interview was conducted with Administrator Rodriguez, in which this report was reviewed and a copy was provided, along with supportive documents. Administrator reported she had no questions regarding the report.