Routine inspection·April 23, 2024

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Maribel Albandie. Administrator Catherine Clark responded to the facility to conduct the visit. A tour of the facility was conducted with the Administrator. The residence was set at 75 F temperature and free of passageway obstructions inside and outside. LPA Doucette observed 4 bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 105 F. Computer room was being used as a staff bedroom and does not show on facility sketch as a fire cleared bedroom. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked cabinet in the dining room area. Cleaning supplies were unlocked in a cabinet in the laundry room. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a pull station fire alarm. Fire extinguishers were charged and had service dates of 10/21/23. There was outdoor seating for the residents.Outdoor shed was unlocked containing pesticides. Resident, medication and staff records were reviewed. Medication error was found for R1. Resident prescription was crossed out where it shows the description of how the prescription should be administered. Facility staff wrote two different start dates on the prescription. LPA took photos. R1 did not have a Hospice Care Plan. Mars log did not have a current log for R1 pertaining to the medication with the two start dates. Current first aid and CPR were on file for staff. Staff did not have training for R1's Hospice Care. Deficiencies were observed and will be cited under Title 22, Division 6. See LIC 809D. Civil Penalty was issued. An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were discussed and left with the Administrator, Catherine Clark, and a copy of this report will be emailed.