Routine inspection·September 11, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Nelfa Reeder, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (3). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility has covered patio space for clients and fenced backyard. LPA inspected the kitchen. Hot water temperature is maintained at 106 degrees F. Facility has sufficient non-perishable and perishable food supply for clients in care. Facility has sufficient cups, plates, and utensils for client use. LPA inspected client bedrooms. Bedrooms are equipped with beds, nightstands, chairs, sufficient linen and lighting. LPA inspected client bathrooms. Bathroom equipment is operating in safe and sanitary conditions. Bathroom hot water temperatures tested between 105 and 106 degrees F. LPA observed the facility is equipped with operating carbon monoxide alarm and operating telephone service. Posters such as complaint telephone number, Ombudsman telephone number, emergency phone numbers are posted in a common area. Emergency drill was conducted on 7/5/23. Facility has a complete first aid kit. Facility has sufficient linen, emergency supplies, and personal hygiene products for clients. Sharps, disinfectants, cleaning solutions, and toxins are kept in a locked cabinet. LPA observed front door signal system was not operating. Administrator stated the signal system was turned off during maintenance. Administrator stated they are not sure when the maintenance person will be returning. Deficiency cited. Client medications are kept in a safe and locked cabinet, inaccessible to clients in care. LPA observed client 1's (C1) medication packet was empty. Administrator stated medication was refilled and will arrive today. Deficiency cited. All staff files reviewed had first aid certifications, fingerprint clearances/exemptions, health screenings, training, and personnel records. All client records reviewed had admissions agreements, physician's reports, assessments, personal rights, and safeguarded resource records. An exit interview was conducted, where licensing reports and plan of corrections were discussed. Copies of reports with appeal rights were provided to the Administrator at the conclusion of the visit.