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25 | On 01/31/2024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with residential social worker James Murch and later met with large program administrator Crystal Hutchinson via telephone to discuss facility plans. LPA explained the purpose of today's visit to both Crystal and James.
LPA toured the facility inside and outside with administrator Monica. While touring the facility LPA tested the water one bathroom in two resident rooms #1353 and #1305. Water is tested at 108F. Resident rooms observed at random are maintained and include the required furniture and lighting per regulations. Residents have an adequate amount of linens and incontinence supplies, incidental supplies, as well as PPE as needed. Two fire extinguishers were checked within the facility. Tagged inspection is dated as 07/03/2023. Extinguishers observed are charged and within operating range including the kitchen's fire extinguisher. Carbon monoxide detectors are present. Facility is hardwired with smoke detectors. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Main kitchen is on the ground floor of the building. Food deliveries are made daily for fresh food items. Longer lasting food supplies such as frozen goods, canned goods, dry goods, etc is delivered two times a week. Residents with modified diet plans or prescription diets are posted and reviewed as in place. Medications are stored and inaccessible in a locked medication room on the 3rd floor. Medications are stored in secured medication carts that are used to disperse medications through out the facility. Double locking is in place for controlled medications. 5 of 5 resident medications are reviewed to be in place and accurately marked. Medication administration record is observed as current for clients reviewed including centrally stored medication log. First aid items are observed in medication room. Additional first aid kits are available outside of medication room through out the facility. On site laundry is available and functioning per observations made. Residents can wash their own laundry in the laundry rooms if they wish, but staff do the laundry regularly for residents. Facility does not handle resident monies. Cleaning supplies are stored in janitor closets observed and are locked in the independent living building. Resident menus are posted as well as activity calendar and daily calendar.
Facility files, including staff files and resident files, are to be reviewed on a later date. Monica informed LPA that her administrator indicated that her administrator certificate is expired as of January 17, 2024 but did submit the required renewal documents and credits to the appropriate department for renewal in December 2023 and is awaiting a new certificate to be sent.
Report is reviewed with Monica. No citations issued. |