Routine inspection·February 15, 2023

On 2/15/23 at 1:23 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Diana Barnhill, Licensee/Administrator, and explained the purpose of the visit. LPA toured the facility with licensee and observed the following: At 1:28 pm, the knife drawer in the kitchen was unlocked and containing sharps. This violates the regulation for care of persons with dementia. Deficiency cited. The facility has signage at the front door regarding the visitor policy and signage throughout the facility on infection control precautions. Screening, hand sanitizer and visitor log were available upon entry. The facility has seven single-occupancy resident rooms and three double-occupancy resident rooms. Each room includes an attached bathroom. Individual resident bathrooms and bathrooms in the common areas were stocked with soap and paper towels. Between 1:37 pm and 2:06 pm, the water temperatures in seven bathrooms were tested and recorded at 125.1F (Room 10), 127.4F (bathroom next to Room 10), 126.2F (Room 9), 130.7F (Room 4), 128.8F (bathroom next to Room 1), 88.7F (Room 2), and 120.5F (Room 3) degrees. Water temperatures are not in compliance of the regulatory 105F to 120F degrees. Deficiency cited. At 2:05 pm, Staff #1 (S1) was wearing their mask below their nose with residents in the facility. The facility did not protect the personal rights of residents in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions. Deficiency cited. The facility has two fire extinguishers, one located in the hall next to the laundry and the other in the hall near the resident tv area. Both are fully charged and were inspected on 8/23/22. At 2:15 pm, LPA conducted the Infection Control mitigation module with the licensee. Exit interview conducted, deficiencies cited, and the report and appeal rights emailed to the licensee.