Routine inspection·May 12, 2023

Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility above. LPA met with Nikole Daugherty, Administrator, and Cathyann Paape, Business Manager, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. Documentation of quarterly emergency drills was not available. Administrator confirms that drills were completed in March/April 2023 and December 2022 and not prior to that. Deficiency cited. LPA toured the facility with the administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council . The facility has 15 bedrooms and 16 bathrooms, a kitchen, dining room, living room, and courtyard in the front of the facility. Medications are kept in a locked room behind the nurses’ station. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke and carbon monoxide detectors were tested and operational. Fire extinguishers (7) are located throughout the facility and were last inspected 9/30/22. One extinguisher was not fully charged. Licensee will get the extinguisher inspected and send CCL a photo of extinguisher by 5/19/23. There are no issues with Fire Clearance. LPA observed cleaning supplies and disinfectants in a locked closet. The facility has cameras inside and outside throughout the facility. Living and dining room furniture were also checked for functionality and condition. The living room and dining room are clean, safe and sanitary. Continued on 809-C. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the front yard. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. External gates have latches and working properly. Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator and freezer were in compliance with temperatures. Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need. Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 110 F and 115 F degrees in resident bathrooms. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Resident records reviewed are in compliance. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. All staff were associated to the facility. TB records were not available in one out of five staff records reviewed. Deficiency cited. First aid certifications were not available in two out of five staff records reviewed. Four out of five staff records reviewed indicate that there is insufficient documentation showing staff met the minimum hours of required annual training. Deficiency cited. Medications are in a centrally stored and locked room behind the nurses’ station, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current. Exit interview conducted, deficiencies cited, and the report and appeal rights given.