Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Licensee (LE), Victor McKenzie and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are five residents, of which three are on hospice during today's visit.

LPA Tea reviewed five resident files and two staff files. Resident files had the required documentation. There were discrepancies in staff files. LPA observed outdated First Aid/CPR training. There is current staff training for one staff last conducted in November 2024. Licensee misplaced the current training for the other staff. There is currently no qualified administrator. The designated administrator nor licensee does not have a valid administrator certificate.

LPA Tea along with the licensee toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms were missing and some did not operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. At first the bathrooms did not have good up keeping but caregivers cleaned up the restrooms afterwards. LPA reminded licensee to maintain the cleanliness of the bathroom and facility. There should be no cobwebs, spiders and other insects at all. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 119.3 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was