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

Licensing Program Analyst (LPA) De Leon arrived at 11:45 am to conducted a 1 year annual continuation visit to the facility above. LPA met Administrator Ronald Freeman and explained the purpose of the visit. 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, medication were reviewed for expirations dates. No medications labels were altered. 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 Resident Services Director. Staffing: The facility employes 67 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 10 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 10 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 staff met most requirements with some not meeting exact hours and or subjects requirements. Staff handling medications had 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. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Ten files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals were not in files reviewed. The facility does not handle cash resources for residents in care. Facility does submit incident reports to the department when required. Exit interview conducted and copy of report printed for Administrator.