LPA, accompanied by the administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to residents measured at 150 F..

There were at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to clients. Some Medications were locked, however, the medications requiring refrigeration were not locked and accessible to residents. According to the administrator, Resident #1 (R1) refuses medications. Therefore, R1's medications are being crushed by the facility staff with no crushing order on file. Also, administrator stated the crushed medications are being camouflaged in the resident's food. LPA reviewed multiple staff and resident records/files. There were two residents, R1 and Resident #2 (R2) with half bed rails, and no bed rail orders on file. The facility does not have a plan for resident shelter accommodations in the event of an emergency. Also, disaster drills are not being conducted. R2 has a diagnosis of a Major Neurocognitive Disorder and does not have a current Physician's Report. Multiple residents do not have a current Resident Appraisals on file. The administrator was made aware Admission Agreements were not updated to reflect laws.