Routine inspection (multi-day)·April 18, 2024

Licensing Program Analyst (LPA) Teresa Camara arrived unannounced to conduct a continuation of the required annual visit. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit. LPA reviewed the plan for repairing the delayed egress doors with the ED and maintenance director. The facility had two companies come out to inspect the doors and provide bids. They are awaiting the final bid from one of the companies and will get time frames from that company on ordering parts necessary for repairing the doors and completing the actual repairs. In the meantime, the facility has increased staffing in the memory care unit. The facility provided documentation showing the fire alarm system, including smoke detectors and carbon monoxide detectors, were last inspected by Boyd & Associates on 1/12/2024. The administrator is updating the Emergency Disaster Plan and will have it complete by 4/30/2024. In addition, the administrator will conduct quarterly evacuation drills on all shifts starting on or before 5/10/2024. LPA reviewed medications for five residents. One resident's centrally stored medication and destruction record (CSMDR) was incomplete. However, based on the facility's medication administrator record it appears the medications are given as prescribed. The administrator will ensure all CSMDRs are up to date. LPA reviewed five staff files which were complete. One staff is updating their first aid/CPR but is not on the schedule at this time. There were four residents' files needing updated and/or signed needs and services plans which the administrator is currently working on. One of the residents will need an updated medical assessment to address a possible increase in care needs. LPA interviewed three staff who gave appropriate responses to the questions. Exit interview conducted. A copy of the report issued.