LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control:

• Infection control practices and Personal Protective Equipment (PPEs) were observed.
• There is a visitor sign-in station located in the main entrance lobby.
• The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.
• Facility has COVID-19 signage posted throughout the facility including notification at the front door of exposure to Covid-19 if an individual visits the facility. According to the Administrator, ten (10) residents had been tested covid positive between 8/23/23 – 8/25/23 but have now been cleared. LA Dept. of Public Health had visited and assessed the facility last week and there were no additional recommendations given. Although there are currently zero (0) covid positive cases, the facility continues to conduct covid testing 2x a week until cleared by LA Dept. of Health.
• Staff are adhering to infection control requirements.

• A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
• Hospice Waiver for 30 is approved.
• A fire clearance is in place. Fire Drill was last conducted on 08/07/2023 at 2:55pm.
• 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 07/01/2024.
• Surety bond (Worldwide Insurance Specialists) of $50,000.00 is current.

• The facility is a two story building which consist of: First floor: Lobby, 4 dining areas, forty four (44) resident bedrooms (including Memory Care) with an attached bathroom, family room, reception area, administrator office, 4 common restrooms, 2 medication rooms, kitchen, storage rooms, cooler, electrical room, employee lounge, game room, conference room and outdoor seating area. Second floor: Seventy six (76) resident bedrooms with an attached bathroom, beauty shop, records room, storage room, staff break room and foyers. The facility is licensed to serve age range 60 and over. 252 non-ambulatory, of which 5 may be bedridden. Bedridden rooms #136, #102, #103, #104 and #112. Hospice waiver for 30.
• 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.
• Cleaning supplies and toxic substances are inaccessible to residents.
• LPA tested hot water temperature in eight (8) random rooms (Rooms #101, #103, #132, #129, #217, #224, #232 and #264) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

• A total of seventy eight (78) staff members including the Administrator provide care and supervision to the residents.
• Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

• LPA reviewed five (5) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current.
• Administrator certificate is valid and expiring on 07/12/2025.

• Resident files are maintained at the facility. A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records.
• RCFE complaint poster and Personal rights were observed posted outside the reception desk.
• The Incident report binder was reviewed.

• Resident personal rights are posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone.

• Sufficient space to accommodate both indoor and outdoor activities was observed.
• LPA observed an activity calendar posted by the dining room and in the elevators.
• The facility has a Resident Council.
• Facility provides equipment and space to accommodate both outdoor and indoor activities.
• Weekly activities had been developed.

• Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
• Physician orders for modified diets are on file.
• Sanitation practices and kitchen cleanliness was observed.
• Kitchen staff workers were observed to be wearing masks and disposable gloves while working.

• Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications.
• Medical and dental transportation is provided.

• Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place.
• Records of resident Appraisal and Needs services plans are part of Emergency training.

• Currently, ten (10) residents receive hospice care and zero (0) bedridden resident.
• There is an adequate number of direct care staff to support residents needs.
• Half bed rails for mobility assistance were observed in some resident beds.
• Functional Capability and Pre Placement Appraisals are on file.
• One (1) resident has prohibited health condition and is under Hospice care.
• "Oxygen In Use" signs were posted on the resident doors who are using oxygen.