KITCHEN/GARAGE: The LPA inspected the kitchen/food service area at 09:49AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Knives were stored locked and inaccessible in a kitchen drawer and cleaning solutions were stored in a locked cabinet under the sink. Fire extinguisher by the kitchen area was fully charged and last purchased on 12/27/2024. LPA observed a locked garage adjacent to the kitchen that contained a washer and dryer, additional refrigerator/freezer, and additional food and supplies.

BEDROOMS: There are five (5) resident bedrooms of which four (4) are designated for single-use and one (1) is designated for shared-use. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed a locked staff room in the hallway. All direct exits were clear, and no obstructions were noted.

RESTROOMS: There are four (4) restrooms of which three (3) are designated for resident-use and one (1) is designated for staff and visitor use. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The restrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Hot water temperatures were measured in resident bathrooms and were above 120 degrees F. Staff lowered water temperature and was measured within the required range.

Report Continued on LIC 809-C

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate which was observed to self-latch and self-close. No bodies of water noted.

MEDICATION REVIEW: At 10:20AM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a closet in the entry hallway. All medications including PRNs were labeled, stored, and locked inaccessible to residents. LPA observed six (6) medication errors for discrepancies between logged start dates and pill counts. LPA observed medications not stored in their originally received containers as medications were prepared for a week in advance in pill boxes. LPA observed an evening medication for Resident #1 (R1) being administered in the morning. Administrator stated they will conduct medication trainings with all staff and not prepare medications for more than one (1) day in advance.

RECORD REVIEW: Beginning at 11:04AM, LPA reviewed four (4) out of four (4) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are not conducted quarterly.

Exit interview conducted, report issued, and appeal rights provided.