The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of six (6) residents, age range of sixty (60) years of age and older. The facility is approved for six (6) non-ambulatory residents, of which two (2) may be bedridden. The facility has an approved Hospice Waiver for seven (6) residents. The physical plant of the facility contains a kitchen, living room, Staff office area, owners quarters room, laundry room area within a screened patio area, six (6) resident bedrooms, with half of the resident bedrooms containing private-half bathrooms. Bedroom #3 has a resident bathroom across the hallway. Bedroom #2 is an employee room and always remains locked, inaccessible to residents in care. The facility contains an outside area including a screened patio with furniture and shade as well as a backyard area for residents to utilize for outdoor activities with a gazebo area in the backyard with furniture and shade.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). Additional perishable food items were maintained in a storage area in the garage of the facility as well as an extra refrigerator and extra freezer located in the garage of the facility. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to residents are kept inaccessible to residents in the kitchen area. Continued on 809-C

COMMON AREAS: At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There is a fireplace in the facility, located in the dining area/living room that is covered an inaccessible to residents. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has multiple fire extinguishers that were fully charged and serviced annually, the last service of all fire extinguishers being February 2023. This is a single-story facility with a main living room area, kitchen area, dining room, laundry room, 6 resident bedrooms, 6 resident bathrooms resident restrooms, a locked centrally stored medication containment area, extra storage areas for additional perishable food, cupboards in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents such as television, puzzles, games, etc. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. The facility contains a screened patio area that leads out into the backyard of the facility. This screened patio area contains the laundry area for the facility. There is a main entrance walkway into the facility and an administrative entrance area for visitors. The facility has electronic auditory systems on all doors that can exit the interior of the facility, with a loud noise when a door exiting the facility is opened.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The exterior of the facility has a closed perimeter which consists of a wall/fence around the entire facility with latched gates. Inside of the perimeter is the outdoor/outside activity area for residents with a gazebo/patio in the backyard, furniture, shade, and two (2) small sheds that are locked and contain outdoor maintenance materials. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There are no bodies of water noted on the facility property. Contd. on 809-C

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms in the facility with 1 individual resident per bedroom. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. All resident bedrooms except for one (1) have their own private bathroom consisting of a sink, toilet, and in some cases a bath/shower.

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are six (6) resident bathrooms in the facility. All restrooms inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the resident restrooms. The facility maintains both a communal restroom for residents in the hallway of the facility, as well as personal restrooms for residents in specific bedrooms. Continued on 809-C

RECORDS: The facility keeps confidential storage of resident records as well as Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Personnel records, Health assessments/screenings with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, Criminal record Statements/Criminal record clearances, first aid/CPR certification that is not expired, appropriate training, and Abuse Reporting Requirements. All staff members’ personnel records had the appropriate documentation with no expiration of any training. Administrator Certificates are current and valid. Resident records were reviewed for Pre-Admission/Placement appraisals, Admission Agreements, Physicians Reports with TB Clearance, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS)/Resident Care Plan Report with Updates, Resident Assessments, Self-management of medications if applicable, Medication Orders, Medication Logs, and Inventory of Personal Effects/Management of Resident Cash and/or Valuables/Property. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information.

MEDICATIONS: Centrally Stored Medications are in a locked storage containment cabinet within the Staff Office area of the facility, which remains locked at all times, inaccessible/locked to residents. The Staff Office area with the centrally stored medications is off of the dining room area of the facility. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. The facility maintains individualized resident medication sections, as well as Blood Pressure Logs for specific residents that require monitoring.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. Continued on 809-C

No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.