LPA toured facility with Administrator. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguishers were fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 73 degrees F. Hot water temperature tested and read within regulation requirements. Residents’ rooms are appropriately furnished with adequate lighting, storage and bedding. LPA observed more than two days of perishable and more than seven days of non-perishable food. Food is stored in proper containers in the refrigerator and freezer. A written disaster and mass casualty plan is readily available located on the facility office. LPA reviewed medications and conducted a sample medication audit.. Medications are stored in a locked cabinet in the staff storage room. There is a signed and dated order from a physician for prescription and PRN medication. LPA observed the medication administration record (MAR) and medications are given per physician's orders.

Intern Administrator and LPA conducted a full review of the annual care tools. There was one technical violation noted on documentation of quarterly fire drill. Intern Administrator to conduct drill today (10/23/2023) to maintain regulation compliance. No other technical, citation, or deficiencies were noted on the full annual care tools review.

Exit interview, no deficiencies or citations issued, report given.