Routine inspection (multi-day)·June 22, 2023

On 6/22/23 at 2:36 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced continuation visit to finalize the Annual/Required inspection started on 6/16/23. LPA met with Tammy Westwood, Administrator, and explained the purpose of the visit. Medications are properly labeled and checked for expiration dates. One exception is that staff wrote on the label of Resident #1’s (R1) medications. Technical Violation given. A sampling of resident’s medication show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. R1's centrally stored medication list did not have the Date Started for three prescriptions started on 6/9/23, 6/20/23, 6/21/23. Technical Violation given. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. 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/and current First Aid. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. Administrator states that “All managers have CPR training, one manager is on duty at all times, and there’s an on-call person with CPR training.” One out of five staff files reviewed indicate staff did not receive required Initial Training of 8 hours of Dementia, 4 hours of Postural Supports/Restricted Health Conditions/Hospice Care, 2 hours of Physical Limitations and Needs of Elderly, and 8 hours of Medications. Deficiency cited. Exit interview conducted, deficiencies cited, and report and appeal rights given.