Routine inspection·February 29, 2024

Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Caregiver, Leila Tobias and explained the purpose of the visit. Present at the facility was Administrator Garrett Welker, who left shortly. The facility is a six (6) bedroom, three (3) bathroom one-story home. A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Miss Tobias, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 108 degrees F. The facility had functioning carbon monoxide detectors, multiple smoke detectors, one operable fire extinguisher. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and contained the appropriate medical documents in addition to Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. During today's visit the following deficiency was observed: - The facility did not have a record keeping log of medication given. Deficiency cited. An exit interview was conducted and copy of this report, along with Licensee/Appeal Rights, was provided at the conclusion of the visit.