Routine inspection (multi-day)·July 25, 2024

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit to continue and complete using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Thomas Trice and the purpose of the visit was discussed. The inspection was conducted to completed the remaining (6) domains of the CARE tools: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan. Operational Requirements: The facility has a Dementia Waiver in place. A Hospice Waiver for 4 is approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 3 only. Required Liability Insurance is in place. A surety bond is not applicable. Facility does not handle resident's money. Incident Medical and Dental: LPA reviewed medications for (6) Residents. 30-day supply of resident medications were observed. Centrally Stored Records for medications are kept. Medication stored matches the medication record for each resident. Medical and dental transportation is provided by family members. Residents with Special Health Needs: Four (4) residents receive home health services. Postural support observed for one resident. Physician order is on file. Two (2) residents had full rails. Both residents are on Hospice. Total of (2) Residents are on hospice. No residents have prohibited health conditions. Staffing: Sufficient caregiver staff provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 12/1/2024. Personnel files were reviewed. LPA reviewed a total of (5) Staff fIles including the administrator. LPA observed required documents for each.Proof of staff training was reviewed. Current 1st Aid/CPR records are current. No deficiencies are being cited on todays visit. Exit interview conducted and copy of this report was provided.