Routine inspection·October 4, 2023

Licensing Program Analyst (LPA) De Leon arrived at 10:00 am to conducted a 1 year annual visit to the facility above. LPA met with Back up Administrator Crystal Karen Thavaj and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility is a 5 bedroom and 3 bathrooms currently occupying 5 residents and employs 3 full time live in staff and 2 Administrators. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide was tested and working at the time of the visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen needed additional cleaning around the stove, hood, oven and microwave. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has an fenced backyard for client use with plenty of shade. The gates are in need of repair to be self latching due to normal wear and tear. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 05/01/2024. The facility is approved for a capacity of 6 with 6 Non-Ambulatory of which 6 may be bedridden. Hospice approved for 3. Staffing: The facility employes 3 full time live in staff and 2 Administrators. Facility has 18 back up Staff if needed, Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires 11/15/2023 and 01/25/2023. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have training for 2023 but are not meeting the full 20 hours required, Administrator will make sure all staff met the 20 hour annual requirement and provide proof of training to LPA. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA will return at a later date to review resident files. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas needed additional cleaning of grease around the stove area. The facility currently has A-1 Pro coming out to control insect problem, Administrator provided invoice and is having company come out routinely until eradicated. All of the other areas of the kitchen are clean and sanitary. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical Services : Facility provides transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA will return at a later date to review residents medications and records. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected on 08/01/2023. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not currently have residents with oxygen. The facility has 2 hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has 1 residents receiving Home Health services. Home Health services records are kept on file. The facility does not have delayed egress. The facility has two self closing gates and self latching is wearing and latches need to be replaced. Exit door alarm system is currently not working Administrator provided an invoice dated 09/22/2023 for a part on order to fix the issue. LPA will return to conduct interviews with residents and staff. LPA will return at a later date to complete the annual visit. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator