Routine inspection·January 27, 2025

On 01/27/2025, Licensing Program Analyst (LPA) Melisa Rankin arrived unannounced for an unscheduled visit to conduct a required Annual Facility site inspection visit at the facility above. LPA met with Administrator Dorothy Berger and informed her of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of fourteen (14) Non-Ambulatory residents, of which two (2) may be bedridden. The facility has an approved Hospice Waiver for seven (7) residents. The facility has been approved for a secured perimeter of electronically locked gates/fencing. KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The facility has a sufficient supply of perishable and non-perishable food. Items that could constitute a danger to residents are kept inaccessible to residents in the kitchen area. The kitchen was clean and sanitary. A review of all food items will be done to ensure expiration dates are adhered to. COMMON AREAS: At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. The facility maintained a comfortable temperature of 68 to 70 degrees. Smoke detector(s) and carbon monoxide detector(s) were inspected along with the sprinkler system in October of 2024. The facility has multiple fire extinguishers that were fully charged and serviced in October of 2024. Continued on 809-C This is a single-story facility with a main dining room/living room area, kitchen area, library room, laundry room, 8 resident bedrooms, 4 resident restrooms, a locked centrally stored medication containment area, extra storage areas for additional perishable food, cupboards in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment. The LPA observed required postings throughout the common spaces. All window screens observed were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. OUTSIDE/LAUNDRY/MISCELLANEOUS: The exterior of the facility has an approved secured perimeter which consists of a metal fence around the entire facility with locked gates. The gates are locked through a combination of electronic punch numbered locks as well as traditional key locks. Inside of the locked perimeter is the outdoor/outside activity area for residents with a patio, furniture, shade, a small garden, and a fountain that currently is empty of water and filled with stones. The designated laundry area is where cleaning products are stored, which are kept locked and inaccessible to residents. There was emergency food and water in a storage area pantry next to the kitchen and in the extra perishable food storage area which was observed to be in good condition. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. There is a garage outside of the locked perimeter fence of the facility that contains extra perishable food, hygiene products, PPE material, and cleaning products. The garage is also locked at all times. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are eight (8) designated resident rooms in the facility with either 1 resident per bedroom or shared bedrooms with 2 residents per bedroom. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are four (4) bathrooms in the facility. All restrooms inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. Continued on 809-C The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The facility maintains both communal restrooms for residents in the hallways of the facility, as well as a personal restroom for residents in a shared bedroom. RECORDS: The facility keeps confidential storage of resident records as well as staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Personnel records, Health assessments with Tuberculosis (TB) test results, Criminal record Statements/Criminal record clearances, first aid/CPR certification, and the appropriate training. All staff members’ personnel records had the appropriate documentation. Two staff are scheduled to complete required training this week, administrator will provide completed certificates to the LPA. The administrator is currently Active in the Administrator Certificate listing, expiring in 9/9/2025. Resident records were reviewed for Pre-Admission/Placement appraisals, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, and Needs and Services Plan (ANS)/Resident Activity Assessments. The Needs and Services plan form used by the state is required annually, facility does a more detailed process of doing daily assessment of residents needs, and administrator reviews and adjusts what resident requires as needed. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. Centrally Stored Medications are in a locked room that has a combination electronic lock on the door, which remains locked at all times. LPA audited a sampling of medications for residents. Due to review, House Manager will do an audit of medications, and records to ensure all documents are updated consistently across all shifts by all med techs. Training and update will be provided to LPA. Staff were able to explain and answer all LPA inquires. Document used by the facility include PRN Authorization, centrally stored listing of all medications, pharmacy refill requests, resident refusals, and physician contacts. Continued on 809-C FACILITY DOCUMENTATION: Facility has an approved Infection Control Plan on file with the department. There are required postings throughout the facility, including emergency exit. The facility keeps hard copies of facility documentation such as LIC 500 Personnel Report, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), and a Facility Sketch. Facility will update their Emergency Disaster Plan to the revised state form and provide LPA with a copy of the document. Provider Information Notices are easily accessible and presented to LPA upon request during the inspection process. No deficiencies cited. Exit interview conducted. A copy of the report will be emailed to the facility.