Routine inspection (multi-day)·July 12, 2023

Licensing Program Analyst (LPA) De Leon arrived at 9:00 am to conducted a case management annual continuation visit to the facility above. LPA met Administrator Jodi Beltrama and explained the purpose of the visit. Staffing : The facility employes 38 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Personnel Records & Training : The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Staff handling medications had initial and/or annual training of 8 hours of medication training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, some staff had food handler certificates. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health care plans had training records on file. Incidental Medical & Dental: The facility has a medication room that is kept locked as well as two medication carts which are kept locked. Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cart for all prescription and PRN medications, Doctors orders and house medications for expiration dates. No medications labels were altered. LPA chose 1 random residents medications to review and all requirements were met and followed. The facility has a mini locked refrigerator for medication and an ice chest for emergency use. The facility has a red sharps container for disposal of syringes. Medication Destruct is done by the facility with Administrator and Wellness Director present. Exit interview conducted, No deficiencies cited, copy of report printed for Administrator.