Routine inspection·March 8, 2024

On 03/08/2024 at 08:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were three (3) staff present, and five (5) residents present. Licensee/Administrator Lesley Vannoy was contacted and arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Vannoy. The facility is a six (6) bedroom, three (3) bathroom home with a kitchen/dining area, living room, laundry room and detached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which two (2) can be non-ambulatory residents. The facility has two (2) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #4 (S4) 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). LPA Brown observed no obstructions to outdoor and indoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. Also, LPA Brown observed Resident #5 (R5) with full bed rails and Licensee/Administrator Vannoy reported to LPA Brown that R5 is not on Hospice Care and no written order from the physician was observed indicating the need for postural support/full bed rail. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R5's full bed rail. Deficiency will be issued. To add to that, LPA Brown observed Resident #1 (R1), Resident #3 (R3), and Resident #4 (R4) have half bed rails and no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C *** LPA Brown measured and observed the water temperature in the bathroom to be at 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster and the 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. Moreover, LPA Brown observed one (1) bottle of cleaning supply in the residents' shared bathroom cabinet, not locked and accessible to residents in care. Deficiency will be issued. Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and resident appraisals. The files were complete with updated physician’s reports, admissions agreements, and preadmissions/resident appraisals. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) result. LPA found that Staff #6 (S6) working at the facility with criminal background clearance but the facility did not transfer S6 criminal background clearance to the facility. Licensee confirmed to LPA Brown that S6 had been working at the facility since 08/23/2017. Deficiency and civil penalty of $500.00 will be issued during the facility visit today, 03/08/2024 and will continue to be assessed of $100.00 per day until corrected. Furthermore, two (2) residents medication were audited and LPA Brown observed Resident #4 (R4) one (1) medication dispensed and staff did not update R4's dispensed medication in R4 Medication Administration Record (MAR). Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG, LIC9102TA and Appeal Rights were discussed and provided to Licensee/Administrator Lesley Vannoy.