Routine inspection·August 29, 2024

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Brenda Truing- Administrator who granted entry into the facility. LPA Allen created the report under the incorrect facility number 306006525 the report should have been under 306006112 on 8/21/2024 Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature tested within regulation at 102.5 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated place for client/staff files locked in a cabinet in family room . Overall, the facility appeared to be clean, in good repair, and operating in safe conditions. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians, however LPA observed during the inspection two(2) clients medications were transferred between containers. LPA also reviewed two (2) staff files for First Aid/CPR certification, training's, and health screenings and appeared to be current. Based on the observations made during today’s visit, a citation was issued for transferring medication between containers. An exit interview was conducted, and this report LIC809, LIC809-C and LIC809-D with appeal rights was discussed and provided to Brenda Truing- Administrator at the conclusion of the visit.