Facility Evaluation Report

On 08/29/24 at 1:43PM, Licensing Program Analysts (LPAs) D Panlilio and D Doidge arrived unannounced to conduct a required annual inspection. LPAs met with staff (ADM) and explained the purpose of the visit. LPAs observed ADM has a current RCFE administrator certificate#6050378740 which expires 01/16/25.

At 2PM, LPAs toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 106 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged. LPA reviewed 3 staff and 4 resident files.

Updated copies of the following documents were collected at the facility:

 LIC308- Designation of Facility Responsibility

 LIC610E- Emergency/Disaster Plan including infection control plans

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided .