Infection Control:

• The facility has an Infection Control Plan. A visitor sign-in sheet is in place.

• An Infection Control Plan has been added to the Plan of Operation.
• The facility has a Dementia Waiver in place and an approved Hospice Waiver for 4 residents.
• A fire clearance for 6 non-ambulatory adults 60 and over; of which three (3) may be bedridden in rooms 2, 3, and 4 only.
• Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 10/6/2023.
• A surety bond is not applicable. Facility does not handle resident's money.
• Liability Insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 10/6/2024.
• Facility has an American Red Cross 1st Aid kit and manual.
• No Surety bond is in place. Facility does not handle resident monies.

• The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents, of which 3 may be bedridden. The facility is owner operated and consists of 5 bedrooms; 4 for residents [3 private & 1 shared) and 1 staff bedroom for licensee, 3 bathrooms, living room, dining room, kitchen, outdoor covered patio area, laundry room, and a 3 car detached garage in the rear of the property presently being used as storage area.
• The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The kitchen drawers containing knives/sharp objects was unlocked, and under the kitchen sink and bathroom sink cabinets were unlocked with cleaning products.
• The facility has one (1) fully charged fire extinguisher and fire sprinklers. The last fire inspections was 4/28/2023.
• Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

• A total of 5 caregiver staff provide care and supervision to the clients.

• Administrator certificates expired 3/26/2024. Completed course work documents were sent to the recertification unit on 11/19/2023.
• Personnel files/training were reviewed. Proof of staff training, health clearance, criminal background clearance and 1st Aid/CPR training were verified. Staff (S4) is not associated and was hired on 3/8/24.

• A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, TB clearance, Physician's Orders, medical consent, and medication records. Hospice residents (R2-R4) did not have Appraisal Needs/Services Plans on file.
• RCFE complaint poster and Personal rights are posted; however it was not 20" x 26". Technical Advisory was issued.

• Sufficient space to accommodate both indoor and outdoor activities was observed. Activities are individualized.
• The facility does not have a Resident Council.

• Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
• One (1) resident has a physician order for a modified diet.

• Four (4) centrally stored resident medications were reviewed to verify there is a 30-day supply of medications.
• Medical and dental transportation is provided by families.

• The emergency disaster plan is not updated to the current LIC 610E form.
• The last disaster drill logs was conducted on 8/14/2023; not within the required quarterly basis.

• Three (3) residents are receiving hospice services. Zero (0) resident receive home health services.
• Postural support physician orders were not observed in all resident files. Full and half bed rails for mobility assistance were observed in all resident rooms. No residents have prohibited health conditions.
• Hospice residents (R2- R4) only had appraisals completed upon admission.