Routine inspection·September 30, 2024

On 9/30/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with the Director of Health ad Wellness and explained the purpose of today's visit. LPA Jensen toured the exterior and observed all paths to be free of obstruction. The facility property also has independent living suites on site and a swimming pool. The swimming pool was area was verified to be locked. There are shaded areas and outdoor furniture available for resident use. The facility has numerous activities available for resident engagement. An independent living suite was toured. LPA Jensen toured the interior of the facility including the dining room, hair salon, gym and several gathering areas. The common areas contained adequate furniture and lighting. The kitchen was observed to have a 2 day supply of perishable food and a 7 day supply of non-perishable food. The lunch service accurately reflected what was listed on the menu. The fire extinguisher and Ansul system was last serviced in August of 2024 and is in compliance. The stairways are equipped with evacuation chairs. LPA Jensen toured the resident rooms in assisted living and memory care. LPA Jensen observed a cabinet that had a pillow with a plastic covering that had writing which said for use to cover incontinence stains on upholstered chair. The chair in the room was observed to be stained. LPA Jensen tested the call signal system and care staff responded in a timely manner. The facility currently has 8 residents on hospice. Hospice care plans were on file for all 8 residents. A signed agreement was observed to be on file for a resident sharing a room with a resident on hospice. LPA Jensen conducted interviews with staff members and residents. LPA Jensen reviewed 5 resident files. The physician's report was outdated in 2 of 5 files. Furthermore, the needs and service plans did not accurately reflect the needs of 2 of residents. The facility has 2 residents that have insulin dependent diabetes. 1 of 2 residents that has insulin dependent diabetes has a physician report that makes no mention of this condition. The second resident with insulin dependent diabetes has a physician order stating they are unable to handle their own injections. Both residents with diabetes have a needs and service plan that says med techs will assist with insulin administration. 2 of 5 residents files showed multiple documented falls resulting in serious injury yet no fall mitigation plans put in to place. Deficiencies are being cited and technical assistance is being provided. Failure to correct deficiencies may result in the assessment of civil penalties. LPA Jensen reviewed 4 staff files and found them to be complete with 1st aid certifications, all required training documented, criminal background clearance and health screens. LPA Jensen is requesting the facility provide the following by 10/7/24: Liability insurance LIC 500 Dementia Care Plan Diabetes Care Plan Incontinence Care Plan The facility has an infection control plan and a disaster plan readily available. An exit interview was conducted and a copy of this report was given.