Kitchen: The kitchen area was observed around 11:15 a.m. The facility has a sufficient supply of perishable food items but a little low on non-perishable items. Cleaning supplies and disinfectants are stored in the garage, inaccessible to clients. Knives are stored in a locked cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. At 11:30 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 10/11/2022.

Restrooms: The three client restrooms were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. Around 12:05 p.m., the hot water temperature measured in the client restrooms at 118.2 degrees Fahrenheit.

Bedrooms: There are five (5) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed client records around 9:30 a.m. LPA reviewed five (5) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete.

Continued on 809-C

The last disaster drill was conducted on 4/17/2023.

Medications: Medications review began at 10:50 a.m.; medications are centrally stored and locked in a cabinet in the office. Medications are labeled and checked for expiration dates. The LPAs advised the Staff to ensure that all the necessary information is properly documented on the Centrally Stored Medication Log.

Exit interview conducted. A copy of the report was printed and emailed.