Land of Peace 1

Type of visit: Required - 1 Year

At 11:00 a.m. on 11/06/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. No immediate health and safety hazards were noted during the time of the visit. At 8:45 a.m. today prior to the visit, a file review was conducted of facility documents including but not limited to the Plan of Operations, Dementia Care Plan, Mitigation Plan, Liability Insurance, Facility Application, Facility Sketch, Fire Clearance, Facility Profile, and Personnel Report. A current copy of the facility’s liability insurance was obtained at 12:30 p.m. today. The facility was last visited on 09/08/2022 for a case management visit. It is a single story building with 6 bedrooms, 2 bathrooms, kitchen, laundry room, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which five (05) may be non-ambulatory and one (01) bedridden in Bedroom #5. The facility serves residents with dementia. Approved hospice waivers for six (06). At 11:15 a.m. today, LPA obtained documents including but not limited to the staff roster, resident roster, and resident files for review. At the main entrance, LPA observed a visitor log as well as postings including but not limited to the facility’s visitation policy, non-discrimination notice, a blank copy of the admission agreement, resident rights, rights of resident councils, facility sketch with evacuation routes clearly labeled, and contacts for the Ombudsman and confidential complaints. The facility has 6 bedrooms. 2 bedrooms are designated as staff rooms. The staff rooms were locked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and garage refrigerators, freezers, and pantries. The stove hood was clean. Appliances were in good condition. Sharps were locked below the sink. Cleaning solutions were locked in the laundry area. Medications were locked as well. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked above the appliances. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:10 p.m. LPA measured the room temperature to be 77.5 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility with one (01) resident utilizing the area. The patio contained furniture in good condition. The ramp which led to the emergency exit was in good repair. All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. At approximately 12:20 p.m. the dual-purpose smoke and carbon monoxide detector was tested and operational. Between 11:45 a.m. and 12:20 p.m. three (03) out of three (03) auditory alarms were on and functioning. During today's inspection, the facility was in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 6, 2023

Type of visit: Case Management - Incident

At 3:00 p.m. on 09/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Administrator and disclosed the reason for the visit. An Incident Report was submitted regarding Resident #1 (R1) who was admitted to the hospital after their catheter came off and urine bag was filled with blood. LPA conducted an interview the with Administrator at 3:10 p.m. and conducted a record review at 3:20 p.m. No immediate health and safety concerns were observed. No deficiencies cited. Exit interview conducted. Copy of report issued.the state’s words, verbatim · CDSS document, Sep 8, 2022

Allegation investigated: Staff unlawfully evicted a resident while in care

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit. It is alleged that the facility is refusing to accept resident #1 (R1) back into the facility after being hospitalized. LPA conducted interviews with facility staff from 12:10-12:40pm. Information obtained through interviews reveal that R1 does not reside at this facility but does reside at Land of Peace 3 with a facility number of 197609812. This complaint will be addressed at that facility. Based on the information obtained through interviews this allegation is deemed UNFOUNDED, means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit Interview conducted. Unfoundedthe state’s words, verbatim · CDSS document, May 6, 2022 · control 31-AS-20220506093158

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 9:25 a.m. on 05/03/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. The facility was last visited on 06/30/2021 for an annual visit. It is a single story building with 6 bedrooms, 3 bathrooms, kitchen, office, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory and 1 bedridden in bedroom #5. The facility serves residents with dementia. Approved hospice waivers for 6 residents. Entry: At the main entrance, LPA observed signs for the facility’s visitation and handwashing policies. A posting for “No smoking – Oxygen in use” also hung at the front door. Once inside, LPA observed postings for confidential complaints, Ombudsman contacts, COVID signs, resident rights, resident right councils, neighborhood policy, license, and Administrator certificate. Screening: LPA was screened for temperature and symptoms upon entry. Visitor log documented name and temperature. LPA advised on an additional column for symptom documentation. Bedrooms: The facility has 6 bedrooms. 2 bedrooms are designated for staff. Staff rooms were free from hazards. Of the 4 resident bedrooms, 2 are private and 2 are shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #2 and Bedroom #1 contained Hoyer lifts and beds with half rails. Beds in the shared bedrooms were at least 6 feet apart. Shared bedrooms also had partitions. Bedroom #5 was being refurnished. Bathrooms: The facility has 3 bathrooms. Staff and resident bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:20 a.m. LPA measured the water temperature in Bathroom #1 to be 105.7 degrees Fahrenheit. Kitchen: LPA observed an adequate supply of perishable and non-perishable food. All surfaces were sanitary. Sharp objects were locked. Medications were locked above the stove. Laundry: LPA observed a washer and dryer in good condition. Detergent was locked above the appliances. Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:31 a.m. LPA measured the room temperature to be 71.9 degrees Fahrenheit. LPA observed 2 storage closets by Bedroom #1 and the kitchen with sufficient clean linens. Outdoor areas: LPA observed a covered patio area with seating in good condition. A ramp led out from the living room. The ramp was free from hazards. Hand rails were secure. An additional covered seating area was located on the side of the facility. Safety: All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. Emergency Disaster Plan posted at the front. Evacuation plans with routes labelled were posted throughout. 6 out of 6 auditory devices were on and functioning. The facility uses surveillance cameras inside and outside. At 10:35 a.m. LPA tested the smoke and carbon monoxide detector to be operational. The hallway fire door closed when the detector was tested. At 9:46 a.m. LPA observed a fully charged fire extinguisher near the kitchen. A receipt from 05/13/2021 was attached. During today's inspection, the facility is in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 3, 2022

Allegation investigated: Resident(s) in care sustained multiple pressure injuries. Staff did not meet the incontinence needs of resident(s) in care.

The visit was conducted on Monday, November 15, 2021, but due to a computer err LPA had to return Tuesday, November 12, 2021 for signatures. Licensing Program Analyst Eleza Jackson conducted an unannounced complaint visit to investigate the allegations above. LPA met with the facility administrator and explained the reason for this visit. Upon entry to the facility a physical plant tour was conducted at approximately 11:50am to ensure no immediate health and safety issues were present. LPA Jackson did not observe any immediate health and safety issues. LPA Jackson requested the following documents: staff roster, client roster, client daily activities chart, client wound care log, physicians report(s), appraisals for hospice clients. During the initial investigation it was determined that the above-named facility is not the facility in question. Regarding the allegations above a finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Report reviewed, signed and delivered. Exit interview conducted, nothe state’s words, verbatim · CDSS document, Nov 15, 2021 · control 31-AS-20211112081945