Routine inspection·April 15, 2024

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Kelly Hentzen and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations, posted hand washing guides, and tight-fitting lids on trash cans. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 122 degrees. Deficiency cited. Administrator/Licensee Kelly Hentzen informed LPA Colvin that she has been struggling with the hot water measuring too hot in the bathrooms but then not hot enough in the kitchen. Administrator/Licensee Kelly Hentzen stated that she plans on replacing the hot water heater, as other attempts to repair it have failed. The facility's carbon monoxide alarm and smoke detectors were recently tested for an updated fire clearance on 4/8/24 and were operational. Knives and other sharp objects are kept locked in a cabinet in the kitchen. Chemicals are locked in the laundry room. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 4 residents. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. Resident Records: LPA Colvin reviewed the files for all 6 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the laundry room and is inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Planned Activities: LPA Colvin observed residents participating in various activities, such as puzzles, watching television, listening to music, and exercising. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and are conducting quarterly disaster drills. An exit interview was conducted with Administrator/Licensee Kelly Hentzen and a copy of this report, LIC809D, LIC9098 Proof of Corrections, and appeal rights were provided.