Routine inspection (multi-day)·September 26, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual continuation inspection visit at the facility. LPA met with an explained the reason for the visit. During this visit LPA completed the following domains during today's visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Incidental Medical and Dental, Disaster Preparedness, Residents with Special Health Needs. LPA reviewed Infection Control plan and Emergency Disaster plan both were last reviewed on 7/24/24. A total of (8) staff files were reviewed. Training for staff was reviewed. A hospice file was reviewed. LPA reviewed medication for 7 residents. During medication review LPA observed medication for resident #3(R3) did not have labels on the prescribed medication. Liability insurance was reviewed. The following domains were completed and/or observed during the initial annual inspection visit of 8/27/24: Physical Plant/Environmental Safety, Resident Rights/Information, Food Service, Planned Activities, Resident Records/Incident Reports. Deficiency noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 809D, and appeal rights were provided.