Routine inspection·June 3, 2024

06/03/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Irene Davis and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to assisted living and memory care sections of the facility including resident rooms, common areas, activity room, laundry room, bathrooms, kitchen, storage areas. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. Medication is locked in locked med room. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in December 2023. Johnson Control comes in quarterly to inspect the fire alarm, sprinklers and smoke detector systems. They also come in annually to inspect the ansul system in the kitchen. There are no pools/bodies of water are on premises. Last disaster drill was conducted in February 2024, which was an active shooter drill, the facility has been conducting fire drills every 2 months. Continued on LIC809-C LPA requested the following documents that need to be updated in the facility file: LIC500 Personnel report Deficiencies are being cited as a result of today's inspection and is included on the attached LIC809-D. LPA inspected 10 resident rooms and observed that 1 of 10 bathroom fans was non-operational. LPA observed that lightbulbs in 3 of 10 resident bathrooms were either missing or non-operational. LPA reviewed staff files and 4 of 4 staff files that were reviewed did not have current first aid certificates on file. Exit interview conducted and copy of report was provided to administrator Irene Davis.