Routine inspection·March 27, 2024

On 03/27/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Talwinder Bains arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPAs met with Administrator Darrell Price and explained the purpose of the visit. LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to residents bedrooms, kitchen, dining room, common areas, storage area, and laundry room. LPAs observed the second door of the laundry room to be unlocked and accessible to residents in care. LPAs observed required furniture, and lighting throughout the residents' bedrooms and facility. LPAs observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Hot water temperature was measured at 111 degrees Fahrenheit in a residents bathroom, which is within the required range of 105 to 120 degrees. The temperature in the facility was 75 degrees. First aid kit was completed. LPAs observed fire detectors and carbon monoxide detectors to be operable. LPAs observed the fire extinguisher, located in the dining room, which was last inspected on 12/08/2023. LPAs reviewed fire and disaster drill logs, which are conducted quarterly. LPAs observed required Licensing posters posted throughout the facility. LPAs conducted a file review of five (5) personnel and five (5) residents records. Both personnel and resident records are incomplete. Medications are centrally stored, locked, and appear to be given per doctor order. LPAs compared medications to those being given for three (3) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). Deficiencies are being cited during today's inspection per Title 22 regulations. Exit interview conducted and copy of the report and appeal rights was left at the facility.