Routine inspection·February 21, 2024

On 02/21/2024 at 9:15 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Executive Director (ED), Grayson Tynes, and explained the purpose of the visit. At 9:20 AM, LPA and ED toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, and courtyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. Medications are locked and inaccessible to residents in care. The hot water temperature was measured in the bathroom at 112 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 01/25/2024. Fire drill was last conducted on 01/18/2024. LPA observed required Licensing posters posted throughout the facility. At 10:00 AM, LPA reviewed a total of six (6) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for six (6) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of four (4) staff record. Staff has training in resident rights, abuse reporting, dementia training, first aid and CPR, and other various areas of care provision. No deficiencies being cited during today's inspection. Exit interview conducted and report provided.