The facility is single story house located in a residential neighborhood with an attached garage. At 10:06 a.m. a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) non-ambulatory residents in bedrooms 1-6. The facility's bedridden capacity is approved for one (1) resident. Bedrooms 1,2,3,4 and 6 are approved for a single bedridden resident.

• 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.

INTERVIEWS: Starting at 10:05 a.m. and throughout the visit two (2) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit.

BEDROOMS: The facility has six (6) private resident bedrooms, and one (1) office / staff break area. Bedrooms 1,2,3,4, and 6 have direct exits to the facility. There is no staff room and staff stated that staff remain awake at night. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.

RESTROOMS: There are three (3) total restrooms of which two (2) are private resident restrooms, and one (1) shared /common resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 107.4 - 108.3 degrees Fahrenheit, all within the required range.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 108.3 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in a locked cabinet under the sink and inaccessible to residents in care.

GARAGE: LPA observed the garage which is accessible from the house and the entry way is adjacent to the kitchen, and bedroom 1. The laundry area including a washer and dryer are located in the garage. The garage has two (2) storage rooms, used for storage only. Garage rooms shall not be used for sleeping rooms. Personal hygiene items (shampoos, soaps) were adequate and are stored in the locked garage. Extra incontinence supplies, and personal protection equipment (PPE) are stored in garage. LPA observed facility supplies such as an extra mattress in the storage space. Report Continued on LIC 809-C PAGE 3...

RECORDS: Record review began at approx. 11:13 a.m.

Resident Records: Three (3) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order.

Personnel Records: Five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

MEDICATIONS: Medication review began at approximately 1:20 p.m. Medications are centrally stored and locked in a closet at adjacent to the entrance. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA observed the first aid supplies to be complete, including a thermometer and a current version of a first aid manual located in the laundry room.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the current Limited Liability insurance.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate.

LPA provide the facility with the updated Component III - RCFE Supplemental Handout.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report reviewed and provided.