Routine inspection·July 16, 2024

On 07/16/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Med Tech and explained the purpose of the visit, who then contacted Residential Care Director who arrived to the facility shortly afterwards. Census is one (1) non-ambulatory resident, 10 ambulatory residents, and zero residents on hospice services. Facility is licensed for 1 non-ambulatory, 32 ambulatory residents, hospice waiver of 1. During today's visit, LPA and Residential Care Director conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: dining room, medication room, five residents room and the common areas. LPA observed kitchen to be fully staffed with cooks, where residents are unable to enter to access sharps. Laundry room is kept locked at all times. LPA observed medication carts to be locked and inaccessible to residents in care. LPA conducted a random medication count for four residents in care. LPA observed medications to be accounted for. File review was conducted for five residents files and five personnel files. LPA observed the required documents present in file. Additionally, LPA provided facility a copy of §1569.625 Staff training; legislative findings; contents and §1569.312 Basic services requirements. LPA and Residential Care Coordinator discussed conservatorship of R1. LPA advised facility to keep documentation of facility attempts and contacting county judge if needed. Residential Care Coordinator reported no additional concerns at the moment. At this time, LPA is requesting a copy of facility liability insurance and LIC 500 by Monday July 22, 2024. No deficiencies observed. Exit interview and a copy of report was provided.