Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72, 76, 77, 77, 73. 73, 75, 75 and 71 degrees Fahrenheit. Water temperature measured at 120, 112, 105, 105, 105, 106, 112, 107, 110 and 105 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed that the facility had a broken tile on a resident's sink wall, broken window screen, broken patio gate door, and a smoke and sprinkler annual inspection clearance report missing. Deficiency issued. LPA observed that the facility did not have slip-resistant mats in all of the residents showers. Deficiency issued. LPA observed sufficient furniture and lighting throughout the facility. LPA observed that the facility did not have toilet paper and hand soap in many of the residents bathrooms. Deficiency issued. LPA observed that the facility did not have the quantity sufficient of linens to permit changing at least once per week for all residents. Deficiency issued. The facility is equipped with operating fire extinguishers and carbon monoxide alarms. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept in Med-Room inaccessible to residents. LPA observed that the signal systems were not working in each wing. Deficiency issued.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA observed upon arrival that there was no administrator present during normal working hours. Deficiency issued.

Record Review: LPA reviewed resident files for admission agreements, physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the personnel files were incomplete and missing CPR training, TB testing, and personnel record. Deficiency issued. LPA observed that the facility did not have the personal rights and complaint information accessible to all residents and visitors. Deficiency issued. LPA observed that residents in the facility were not aware of the menu options, activities schedule and phone usage since the notices were not posted in the common area of each wing. Deficiency issued. LPA observed during medication audit that the resident's MARS were not completed with the required information per the medication label; MARS did not have the staff's initials after administering medication; and PRN medication inventory did not match the MARS and physician's orders. Deficiency issued. LPA reviewed the infection control plan, liability insurance, disaster drills and emergency disaster plan. LPA observed that the facility did not have emergency drills conducted quarterly for each shift. Technical violation issued. LPA observed that the Emergency Disaster Plan did not have a date of revision. Technical violation issued.

Deficiencies and technical violations were cited during this visit. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and provided to Administrator, Jennifer Uriza.