The facility's total capacity is approved for six (6) non-ambulatory residents. Facility has hospice waiver for two (2) residents. The current census is five (5) residents.

Kitchen: The kitchen appliances consisted of a stove/oven, refrigerator, dishwasher and microwave oven. All appliances were observed to be functional. LPA/LPM observed enough food supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen drawer. LPA/LPM observed medications belonging to the administrator in the refrigerator. LPA/LPM observed a table in the kitchen with additional food supplies stored on top and underneath the kitchen table.

Common Areas: The living room and dining area is a large space, with the office space in the corner of the living room. The office area included the telephone and internet for resident use. The living room was furnished with sofas, chairs and a table and the dining room has a round table and chairs, appropriate for number of residents. The living room has a television set and a fireplace, secured with a screen. There is a freezer in the dining room, with additional food supplies. Common areas seemed cluttered and LPA/LPM observed several insects and small roaches on dining room table.

Continued on 809-C

• 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.

Bedrooms/Bathrooms: There are three shared bedrooms for resident use. Bedroom #1 has it's own bathroom, with a shared door to the laundry room. There is a another bathroom in between bedrooms #2 and #3. Both Bathrooms have grab bars and a non-skid floors. Hot water temperature was taken from both bathroom and was measured between 117.1 and 117.2 degrees Fahrenheit.

Surrounding Area/Back Yard: LPA/LPM toured the side paths and back yard. The emergency exit gates were unlocked, and paths were free from debris. The outdoor furniture consisted on table, chairs and an umbrella. There is a locked shed for storage. The garage is currently used as a Accessory Dwelling Unit (ADU) or bedroom for the administrator and staff. A citation will be provided for licensee to obtain a permit for the ADU or convert the room, back to garage or storage. There are several exit doors in the facility but auditory devices on two doors were not working and facility currently has three dementia residents.

Medications: The medications are stored in a locked kitchen cabinet. First aid kit and manual was also kep in the medication cabinet. LPA/LPM reviewed the medication record for all five (5) residents to ensure the accuracy of the medication administration. Medications belonging to the staff were also observed in the kitchen refrigerator.

Resident Records: LPA reviewed records for all five (5) residents were reviewed to ensure all required documents were contained. Three (3) out of five (5) residents physician reports noted residents were bedridden. During the visit LPA observed R1, R2 and R3 ambulating or seating in a chair.

Due to time constraints, LPA/LPM were unable to complete today's visit. LPA will return on a later date to address staff records, training records, facility files.

Deficiencies were observed during today’s visit. An exit interview was held. A copy of this report, and appeal rights were provided to the administrator.