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25 | On 06/16/2021 at 8am, Licensing Program Analyst (LPA) Ashley Boothe spoke with facility staff regarding facility risk assessment questions who confirmed no staff or clients have experienced symptoms within the last 10 days. At 11am, LPA arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator, Alma Whitted and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 96, today's census is 60, 4 hospice residents.
LPA interacted with a random number of residents during this visit and observed residents engaging in communal dining and activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, staff offices, and common restrooms. LPA observed facility last conducted disaster drill on 6/14/2021. The temperature inside the facility was measured at between 74*F and 76*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30 *F less than the outside temperature. The hot water was measured at 111*F which is not less than 105*F and not more than 120 *F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed R1's MAR to prescribe Tylenol twice daily, S1 stated medications were administered from house supply. LPA did not observe Tylenol properly labeled and stored for R1's use.
The first aid kit was found in compliance containing: a current edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher inspected on 8/14/2020, smoke and carbon monoxide detectors. LPA observed central heating and air in the facility is non operational, repair work is scheduled and all residents rooms and staff areas have portable air conditioning units and fans in working order to maintain temperature in the facility within regulatory range. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed knives and toxins inaccessible to residents. |