Routine inspection·August 28, 2023

Licensing Program Analysts (LPAs) Melissa Parks and Sarah Benson arrived on Monday August 28, 2023 to complete the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (6) and staff files (2). All resident files contained the required paperwork except 5 residents were missing TB tests/results. Staff files contained the required paperwork. Two staff files reviewed did not contain current CPR/First aid. LPAs were unable to review the facility's fire drill log as no fire drills have been conducted in the past two years. LPA Parks and Benson and Administrator Grace toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage and outdoor area. Water temperatures in both bathrooms measured 129 and 132 degrees F. Facility meets the perishable and nonperishable food requirements. LPAs observed a facility closet being used as a staff living quarters. An immediate $500 civil penalty was issued. See 809-D pages for deficiencies cited during todays visit. Appeal rights were given. Exit interview conducted. A copy of this report was emailed to Facility.