Routine inspection·September 26, 2024

On 09/26/2024 at 2:10 PM, Licensing Program Analyst (LPAs) Melody Brown and Becky Mann made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Brown and Mann met with a staff and was granted entry to the facility. At the time of the visit there was one (1) staff present, and five (5) residents present. Licensee/Administrator Casimiro Jose was contacted and informed of the visit. Licensee/Administrator Jose arrived during the visit. LPAs Brown and Mann explained the purpose of the visit to Licensee/Administrator Jose. The facility is a 4 bedroom, 2 bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which one (1) maybe bedridden. The facility has four (4) Hospice Waiver. The current census is five (5) residents. LPAs Brown and Mann was accompanied by Staff #2 (S2) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant : The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPAs Brown and Mann observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees Fahrenheit. LPAs Brown and Mann inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPAs Brown and Mann observed sufficient lightning. Moreover, LPAs Brown and Mann observed that bathrooms were clean, and appliances were operating appropriately. LPAs Brown and Mann observed grab bars and non-skid mat in the resident bathrooms. During the tour of the facility, LPAs observed the multiple cans of paints, chemicals and nails in the outside cabinet were not locked and accessible to residents in care. Deficiency will be issued. ***Continuation in LIC 809C*** ***Continuation from LIC809 *** Also, LPAs Brown and Mann observed Resident #1 (R1) with half bed rails. Licensee/Administrator Casimiro reported to LPAs Brown and Mann that R1 does not have written order from R1 physician indicating the need for half bed rail for mobility. Deficiency will be issued. LPAs Brown and Mann observed sufficient furniture and lighting throughout the facility. LPA Brown and Mann measured and observed the water temperatures in the bathroom to be at 118 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication room. Food Service : Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Care & Supervision : The facility has an administrator present in the facility. LPAs Brown and Mann observed no sufficient number of staff to provide care and supervision to the residents in care due to no staff is scheduled to work the night shift as required for facility with Dementia residents. Deficiency will be issued. Record Review : LPA reviewed three (3) resident files for admission agreements, updated medical assessment/physician reports, preplacement appraisals. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals. LPAs observed resident #1 (R1) and resident #3 (R3) do not have Preplacement Appraisal maintained in their facility file. Deficiency will be issued. Also, LPAs observed no completed Medical Assessment/Physician Report for resident #2 (R2). Deficiency will be issued. In addition, LPAs reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPAs observed that files reviewed were complete. Furthermore, medications were audited for two (2) residents and LPAs observed resident #1 (R1) and resident #2 (R2) medications were not given per R1 and R2 physician's order. Deficiency will be issued. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed and provided to Licensee/Administrator Casimiro Jose.