KITCHEN: The LPA inspected the kitchen/food service area at 10:39AM with staff. 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. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps were observed in a locked drawer next to the refrigerator. Cleaning supplies and disinfectants are stored in a cabinet next to the dishwasher inaccessible to residents.

COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. At 11:04AM, smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed fully charged and last serviced on 03/19/2024. Auditory exit alarms were functioning at the time of the visit. The washer and dryer are located in a closet next to bedroom #1. The LPA observed detergents and toxins in a locked cabinet above the washer and dryer. The facility has emergency food and water which was observed to be in good condition. The LPA observed a closet with additional cleaning supplies and personal hygiene products locked and inaccessible to residents in care.

(Report Continued on LIC 809C...)

RESTROOMS: There are six (6) resident restrooms and one (1) communal bathroom. Each bedroom has their own bathroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Between 10:48AM – 10:55AM, hot water temperature was measured in resident bathrooms and were between 105.2 degrees F – 106.5 degrees F, which is within the required range.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. LPA observed side gate to self-latch and self-close. No bodies of water noted at the time of the visit.

MEDICATION REVIEW: At 11:05AM, LPA reviewed medications. Medications are centrally stored and locked in a closet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

RECORD REVIEW: Beginning at 11:20AM, 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 conducted quarterly as is required, with the last drill conducted on 09/09/2024.