Routine inspection (multi-day)·March 5, 2024

LPA made subsequent unannounced visit to complete the annual assessment started on 02/27/2024. LPA met with administrator Angela Lee and discussed the purpose of the visit. Today LPA reviewed the following. Operational Requirements: The facility does not accept patients with dementia There 0 bedridden residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: There is a pool on the premises and it is secured as required. Facility has operable smoke and carbon monoxide detectors located in each room and hallways. Knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the resident’s bathrooms and kitchen sink. The hot water temperature in the bathrooms were measured between 121.8 – 129.1 degrees F which is not within required range of 105-120 degrees F. Staffing : There appears to be sufficient staffing at the facility. The administrator's (Angela Lee) certificate has expired, Proof of renewal reviewed. Staff employed are all over the age of 18. Personnel Records-Training : Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Identification & Emergency Information, Original Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Some residents files need Physicians reports. Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visitors can visit anytime. Continue on 809C Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Disaster Preparedness: The facility has an Emergency Disaster Plan but requires updating. Residents with Special Health Needs: The facility accepts and retains residents with special health needs. One resident with special health needs resides at facility. The staff received training on appropriately caring for residents with special health needs. Exit interview conducted, deficiency cited, technical advisories, 809D and appeal rights provided.