Routine inspection·December 19, 2023

Licensing Program Analyst (LPAs) Cheyenne Ratajczak and Cassie Yang arrived unannounced to conduct a required 1- year annual inspection utilizing the full CARE tool. LPAs met with caregiver to contacted Administrator via telephone who spoke with LPAs on speaker phone. Administrator informed LPAs that an annual inspection was conducted by LPA Williams-Lyons in August 2023. LPAs explained that due to the annual inspection being four months prior to anniversary date, it was required for another inspection closer to anniversary date. Administrator stated he is driving and will be at the facility within an hour. During today's visit, LPA Yang and Caregiver conducted a tour of the interior of the facility. LPA Yang observed joint muscle mediation and Magnesium supplement present in R1's room. LPAs advised facility to lock and secure sharps immediately after use. LPA Ratajczak conducted a file review of 3 resident records, and 2 staff records. It was discussed with Administrator that medical assessments need to be done annually. LPA Ratajczak observed R2s LIC602 to be dated 08/23/05. It was further discussed that staff training needs to be done annually. Along with updated CPR and first aid training's. Water temperature observed at 119* indoor temperature at 73 degrees. LPAs completed full care tool. Please see LIC809D Exit interview was conducted a copy of the report and appeal rights were left at the facility.