Routine inspection·October 17, 2024

Licensing Program Analyst (LPA) Erika Miller arrived at 11:30 a.m. to conduct a 1-year required annual visit. LPA met with Amelita Aquino, Administrator. 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 at least 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: LPA was authorized to enter and inspect facility. LPA toured resident rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on 9/26/23. Administrator provided proof that inspection is scheduled for 10/18/24. The facility has a carbon monoxide and smoke detector that were tested and working. 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 is approved for a capacity of 6. The fire clearance is granted for 4 non-ambulatory and 2 ambulatory residents. Facility has a hospice waiver for 6. The facility to currently has 2 ambulatory and 2 non-ambulatory,1 of which is temporarily bedridden. (Continued on 809-C) Staffing: The facility currently employs 5 staff and 1 administrator. Files reviewed had current1st Aid/CPR, Personnel Records/Application, TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. 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 reports, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible. Food Service: . 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 and are inaccessible to residents in care. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, 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/training on 9/12/24. 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. Exit interview conducted and copy of report printed.