Routine inspection·November 16, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Melanie Niez, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (156) with a current census of (106). Hospice waiver for (20). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: PHYSICAL PLANT/INDOOR: Indoor passageways are free of obstruction. The facility has sufficient indoor space for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. LPA inspected (6) resident bedrooms. Bedrooms were equipped with sufficient furniture, lighting, and bed linen in good repair. LPA inspected (6) bathrooms and (1) central bathroom. Bathrooms were equipment with grab bars and maintained in operating condition. Bathroom hot water temperatures measured between 105 and 107 degrees F. The facility is equipped with operating carbon monoxide alarms, telephone service, and laundry equipment. The facility has sufficient blankets, towels, and hygiene products for residents in care. Resident activities, Licensing complaint poster, Ombudsman poster, emergency phone numbers, evacuation plan, and "No Smoking-Oxygen in Use" signs were posted in the appropriate areas. Sharps, disinfectants, cleaning solutions, and toxins were kept locked and inaccessible to residents. PHYSICAL PLANT/OUTDOOR: Outdoor passageways are free of obstruction. Facility has no outdoor bodies of water. Courtyard area is protected from traffic and sufficient for resident activities. CARE & SUPERVISION : Facility has 24-hour/7 days a week care staff. FOOD SERVICE: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. MEDICAL RELATED SERVICES: Facility has complete first aid kits. Medications were observed locked and inaccessible to residents. Medications for (6) residents were inspected. Medications for resident #1 (R1) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #2 (R2) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #3 (R3) were observed to be in a zip lock bag without a prescription label. Medications for resident #4 (R4) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation as to why medication was not given. RECORDS REVIEW: Administrator certification expires on 8/18/2024. The last emergency drill was conducted on 11/07/23. Records for (6) staff were reviewed. The facility did not maintain verification of food service training for staff #1(S1) on file. The facility did not maintain verification of staff #2 (S2) CPR/first aid training on file. Records for (6) residents were reviewed. The facility did not maintain record of R3's preadmission appraisal on file. Deficiencies are being cited during today's visit and a plan of correction was reviewed with the Administrator. Copies of licensing reports discussed were provided to the Administrator with appeal rights at the conclusion on the visit.