Routine inspection·May 24, 2024

Licensing Program Analyst (LPA) Miller arrived at 8:26 am and made an unannounced 1-year required annual visit to the facility above. LPA’s met with Nereida Leal, back-up Administrator and 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. The facility has EPA approved disinfectants sprays 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). Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on May 18, 2022. Administrator immediately called for an inspection to be completed and will provided proof of new inspection as soon as completed. All trash cans and wastebaskets have tight fitting covers. The facility is a 4 bedroom and 3 bathroom facility currently occupying 4 residents. There are 2 additional restrooms inaccessible to residents and for staff only. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested. 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 for safety. Continued 809-C Disinfectant, cleaning solutions are inaccessible to residents in care locked and stored in the laundry room and or locked under kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has current liability insurance and expires on July 1, 2024. The facility has a current plan of operation on file with the department. The Facility is not operating in compliance with the granted fire clearance. The facility is approved for a capacity of 4. The fire clearance is granted for 4 Ambulatory of which 2 may be non-Ambulatory. However, facility currently has 2 Ambulatory, 1 non-Ambulatory and 1 Bedridden resident. Staffing: The facility currently employs 6 full time staff, 1 part time staff and 1 administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires January 26, 2025. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 4 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, (TCRC IPP), Emergency and ID forms, all forms were legible, and records are kept confidential. 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. Continued 809-C Incidental Medical Services: Facility provides transportation or assists in providing 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 reviewed residents medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill March 9, 2024. 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. The facility has 2 self-latching gates on side of the home. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working. Exit interview conducted and copy of report and appeal rights printed for Administrator Civil Penalty issued (see LIC 809D).