Routine inspection·June 20, 2024

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 6/20/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was not available to assist. Inspection completed with staff assist LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPA noted hot water temperature in the middle bathroom measured at 140 degrees. LPA advised residents be notified, a excessive hot water sign be posted while temperature is corrected. The other hot water control in the non-ambulatory end of the home is non-functional. Staff are using a door stop in the fire door. The practice is to be discontinued. An Ombudsman posted was not observed. Licensee to contact the Ombudsman's office. LPA reviewed 6 resident files. 5 of 6 residents do not have updated needs and service plans on file within the past 12 months. R6 has a diagnosis of dementia and needs a updated physician's report. LPA advised consistent use of a LIC 602a or the equivalent for senior medical assessments for all residents who are seniors. LPA reviewed 2 staff files. Files are incomplete. S1 and S1 do not have health screens present on file. Training that is conducted on line was inaccessible. Licensee to send proof of training for S1 and S2 Deficiencies are being cited , on page LIC 809-D of this report, as a result of todays inspection. Exit interview conducted with licensee and copy of report and appeal rights left at the facility.