Facility Evaluation Report

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Nora Clemons, Administrator, and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6) non-ambulatory, and a current census of (5) residents. LPA conducted an inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a comfortable temperature. Resident bedrooms were furnished with beds, bed linen, night stands, storage space, and sufficient lighting. LPA observed Resident #1 (R1) utilizing a bed with half bed rails without a physician's order on file. LPA observed resident#2 (R2) and resident#3 (R3) utilizing full bed rails; however, Administrator stated that the two residents were not receiving hospice care. Resident bathrooms were maintained clean and fixtures were operating properly. The hot water temperatures in the bathrooms measured at 111 degrees F. The facility is equipped with smoke/carbon monoxide alarms, fully charged fire extinguishers, covered fireplace, first aid kit with manual, laundry equipment, and telephone service. Posters such as personal rights, the Community Care Licensing complaint poster, Ombudsman poster, and facility license were posted in a common area. LPA observed cleaning supplies and disinfectants were kept unlocked and unattended in resident bathrooms, facility hallway table, and accessible garage. LPA observed sharp knives and scissors with stored in a kitchen cabinet where the lock was broken.