Routine inspection (multi-day)·March 28, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit for an annual continuation by using the CARE inspection tool. LPA met with Denise Miller Office Coordinator an explained the reason of the visit. On 3/26/24 LPA Flores completed The CARE tool domains of Physical Plant/Environmental Safety and Food Service. During today's visit LPA reviewed 10 resident files and 10 staff files. LPA observed Appraisal Needs and Service Plan for resident #6 (R6) was last updated on 9/1/22 and #9 (R9) was last updated 1/6/23 which was not updated within the last 12 months. LPA reviewed Infection Control Plan last reviewed on 3/1/24, Emergency Disaster Plan last reviewed on 2/6/24 , Fire drill log (last fire drill conducted on 3/8/24), In-Service training file. LPA observed 20 hours of training. However, in service training did not include 4 hours of hospice care, postural support, and restricted health conditions/health services. LPA conducted interviews with 5 residents and 5 staff. The following CARE tool domains were completed during this visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, Residents with Special Health Needs. Deficiencies were noted in LIC 809D per Title 22 Regulations. Exit interview was conducted with Lori Lackey and a copy of this report, LIC 809D, and appeal rights were provided.