Routine inspection (multi-day)·September 23, 2024

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a continuation of the required annual visit at 09:43AM. LPA initially met with facility staff. Licensee/Administrator was contacted via telephone and arrived at 09:50AM. Entrance interview conducted. This visit is a continuation of the annual visit that began on 06/12/2024 and the physical plant was inspected during the initial visit. During today's visit a brief facility walk through was conducted. Please note: the facility is a 2-story house; the upstairs area is inaccessible to residents in care and is used for staff only, therefore was not observed. RECORD REVIEW: Began at 10:05AM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents. EMERGENCY DISASTER PLAN : During today's visit, LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 08/02/2024. MEDICATION REVIEW: Medications are stored in a large locked pantry. Medication review began at 12:17PM. Medications for 2 (two) residents were observed. Medications reviewed were documented and labeled in accordance with regulation. DOCUMENTS REVIEWED: LPA observed a copy of the facility's liability insurance. No citations issued. Exit interview conducted. A copy of the report was provided.