Routine inspection·February 12, 2024

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility for a required annual inspection. LPA met with facility staff who notified Licensee Carina Davis, who arrived shortly during today's visit. The facility is approved for a Hospice Waiver for six (6) residents. Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents for common areas. All ramps and passageways are kept free of obstruction. Bathrooms have grab bars for each toilet, bathtub and showers used by residents. Fire safety plan includes fire extinguishers purchased on 02/07/2024 and fire alarms. Carbon monoxide detectors are present in the bedroom hallway. Kitchen and Food Service: LPA was present during lunch time. Food provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is at least a two day supply of perishable food items and a seven (7) day supply of non-perishables. The refrigerator and separate freezer are maintained within regulatory temperatures. Medication, Care, and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. Chemicals, sharps, and hygiene items are stored inaccessible to residents. LPA reviewed centralized medications list and inspected medications. LPA found medications kept in their original containers and appear to be dispensed according to the physician's orders. Resident and Staff Files: LPA reviewed a sample of staff and resident files. Staff files had the required documentation including a health screening report and proof of background clearance. Resident files had the required documentation including admission's agreement, appraisal and/or needs and services plan, and updated physician's reports. Current first Aid/CPR certificates are on file. LPA reviewed training for Dementia care and Activities of Daily Living. Operations and Administration: Emergency and Disaster Plan is present. Licensee is present in the facility a sufficient amount of hours and their administrator certification is up to date. The required licensing and ombudsman posters are posted. Residents rights are posted and a copy is kept the resident's file. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Licensee Carina Davis.