Routine inspection·January 6, 2025

Licensing Program Analyst (LPA) arrived at 12:00 pm to conduct a 1 year annual visit to the facility above. LPA met with Administrators Roxandra Whitestine and Rachelle Tellez LPA explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. 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 binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. 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). Operational Requirements: The facility has a current plan of operation 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 April 2025. The facility is approved for a capacity of 22. The fire clearance is granted for 22 Non-Ambulatory of which 18 may be bedridden and Hospice is approved for 8. Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on May 9, 2024. The facility is a 17 resident bedrooms currently occupying 15 residents and employs 20 staff and 2 Administrators. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in cupboards and closets. The facility has sufficient space inside and outside for activities and visiting. The facility has plenty of shade. The facility has telephone and internet service for resident use. Staffing: LPA will return at a later date to review staff files. Personnel Records & Staff Training: LPA will return at a later date to review staff training records Continued 809-C Resident Rights/Information: The facility had postings for Personal Rights and non- discrimination, Emergency Disaster plan, Facility sketch, Visiting policy with hours, Rights to Resident Council and family council. All postings were posted at front entry or in the common areas of the facility. Complaint poster was 20/26 in size and posted at entry. Planned Activities: The facility has a large room for activities and plenty of supplies for activities in two large cupboards, any items that can pose a danger were inaccessible to residents in care. The facility has an acitvity calendar posted at front entry. 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. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical and Dental: The facility provides or assist in providing transportation to medical and dental appointments. The facility has a locked medication room for all centrally stored medications, PRN medications, and first aid supplies. Medication room has a red sharps container for disposal. Administrator and another staff work together to destroy medication at facility when required. The uses an electronic Medication Administrator Record (MAR) and uses the Centrally Stored Medication and Destruction Record (CSMDR). All medications was audited for expiration dates, altered labels and medications stored in original containers no deficiencies found. Resident Records & Incident Reports: LPA will return at a later date to review resident records and reports. Disaster Preparedness: The emergency plan was posted with all required emergency evacuation and procedures. The facility is prepared with a generator, has emergency food supply and water to be self reliant for 72- hours. The disaster drill are being conducted quarterly and facility completed different disaster and scenarios for each drill. Residents with Special Health Needs: The facility does accept dementia residents in care. Facility only has resident on oxygen as PRN prescribed, signs are posted on resident doors. The facility currently has hospice residents in care. The facility currently has residents receiving Home Health services in care. The facility keeps all plans on file and up to date. The facility does not have delayed egress. The facility has a large driveway with gate at entry and a calling system to access gate for car entry. Exit interview conducted and copy of report printed for Administrator.