Routine inspection (multi-day)·March 16, 2023

LPA made subsequnt visit to complete annual inspection that was started on March 9, 2023 LPA met with Administrator Tiffany Vander Poorton and explained the purpose of the visit. Staffing : There appears to be sufficient staffing at the facility. The administrator's (Tiffany Vander Poorten) certificate has expired. Administrator has submitted for renewal on 11/21/2022 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 - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours were posted during visit. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination. Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed all 6 residents' medication and observed some PRN to not have labels attached to containers. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen. (Continued on 809C) During the visit today, LPA observed some deficiencies and are indicated on the LIC809D. Technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Administrator Tiffany Vander Poorten.