Routine inspection (multi-day)·July 26, 2023

On 7/26/23 at 11:39 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced continuation visit to finalize the Annual/Required inspection started on 7/14/23. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit. Medications are centrally stored in a locked medication room. Medications are properly labeled and checked for expiration dates. A sampling of residents’ medications show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid has all proper items and is current. In 2 out of 2 residents’ medications/bubble packs, medications (2) were set aside in advance for two days. Medications can only be stored in a separate dispenser within 24 hours of dispensing to resident. Technical violation issued. Administrator will conduct a training with all med-techs and send CCL the training sign-in sheet by 8/2/23. Staff files : All required training has been completed. On the Annual Inspection Report dated 7/14/23, the facility was cited for Staff #1 (S1) not being associated with the facility, however, the Deficiency Report (LIC 809-D) and Civil Penalty did not print. LPA is providing the LIC 809-D and civil penalty to the administrator at this time with a correction: The Annual Inspection Report (LIC 809) dated 7/14/23 states “S1 was not associated with the facility during their entire time working in the facility.” The correction is that S1 was employed in August 2021 and employment ended in July 2023. Licensing records indicate S1 was associated from August 2021 through June 2022, and not associated from June 2022 through July 2023. Exit interview conducted, deficiency and civil penalty issued, and report and appeal rights given.