Routine inspection·March 28, 2024

Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility for a required annual inspection. Entry into the facility is unobstructed and LPA met with administrator Breanna Redwine. The facility is approved for a Hospice Waiver for six (6) residents. LPA and ADministrator toured the interior and exterior of the facility. Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents. All passageways are kept free of obstruction. Hot water temperature was measured in all bathrooms and measured between 105 and 110 degrees Fahrenheit. Grab bars, textured shower floor, and shower aid equipment are utilized by residents. Fire safety installations such as extinguishers, sprinklers, and alarms are present. Fire extinguishers were observed to be charged and last inspected on 08/04/2023. A hallway smoke detector was tested by facility staff and all other units, including bedrooms, were found to be interconnected and working. Overall the facility is in good condition; it is clean, sanitary and free of foul odors. Kitchen and Food Service: LPA was present during lunch service. The total daily diet provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is at least a one week supply of nonperishable foods and two days of perishable food items, which meets regulatory requirements. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Sharps and cleaning agents are kept secured in the kitchen. Medication, Care, and Supervision: The facility has sufficient and competent staff to provide services needed to meet resident needs. Chemicals and items which can constitute a danger are stored inaccessible to residents. LPA inspected medications and found them in their original containers. Medications appear to be dispensed according to the physician's orders. Resident and Staff Files: LPA reviewed all staff and resident files. Resident files had the required documentation including admission's agreement, consent forms, and appraisal and/or needs and services plan. Staff files had the required documentation including mandated reporting, health screening report, CPR certification. LPA Fannell did not observe updated training related to hospice care and dementia care. These pose potential health and safety risks to residents in care. Operations and Administration: Disaster Plan is present and Administrator Redwine will be updating the plan as needed. Administrator is present in the facility a sufficient amount of hours and their administrator certification is up to date. The required ombudsman poster is posted and Administrator posted licensing poster in public view. Residents rights are posted and a copy is kept the resident's file. Refer to LIC809D for deficiencies were cited during this visit. Technical advisories and violations were issued in relation to deficiencies observed. An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed and provided to Administrator Redwine.