Routine inspection·April 18, 2024

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with administrator Abigail Vue during today's inspection. Currently there are 12 residents residing at the facility of which 2 are receiving hospice care services. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 4 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, and outdoor spaces. In the areas toured no immediate health, safety, or personal rights violations were observed. This facility has an approved delayed egress system. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 5 resident files and 5 staff files. LPA reviewed 3 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance. LPA observed not all care staff had updated CPR and first aid certificates, and health screenings. In addition resident records were found to be incomplete. Deficiencies are cited on 809-D. Exit interview conducted and appeal rights provided.