Routine inspection·December 1, 2023

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Marvia Brown, caregiver, who contacted Nicoleta Hegseth, Administrator, who arrived at 1:10 pm. LPA observed (4) residents in the common area and (2) residents in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Currently, there is (1) resident on hospice. LPA and the Administrator toured the interior and exterior of the facility including the common areas, (2) private resident bedrooms, (2) shared resident bedrooms with a bathrooms each, (1) separate bath with a walk-in shower, kitchen, staff room, locked laundry area and garage. LPA observed the facility to be clean, in good repair and odor-free, and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable, including fresh produce, and 7+day non-perishable supply of food. Sharps, daily medications and toxins are locked in the kitchen. Medications are also secured in a separate cabinet in the laundry room. LPA observed sufficient linens/blankets/incontinent supplies, PPE, and a complete First Aid kit. The inside temperature was 76*F. Hot water temperature measured 108*F in the kitchen. Fire extinguisher last serviced 10/6/23. Quarterly fire drills conducted -last drill 10/25/23. Smoke/monoxide alarms working. There is a large backyard area and patio with covered seating and an unlocked gate. All required postings are posted, including Theft & Loss, Personal Rights. Activities are on hand. LPA reviewed (3) resident files and found them to be complete and contain current paperwork. Medications were reviewed for (2) residents and no discrepancies were noted. Medication documentation is current and accurate and PRN dosages are being documented. (2) staff files were reviewed. Both staff have current First Aid/CPR and have completed the required initial/ongoing training. Administrator has current RCFE Certificate #6058750740- exp 2/15/25. All staff are finger print cleared/associated. LPA reviewed/approved the Infection Control Plan and the Emergency Disaster Plan. . LPA obtained updated copy of LIC308 and LIC500. LPA obtained land line. LPA to provide information on Guardian system. There are no deficiencies issued. Copy of report provided to Administrator.