Facility Evaluation Report

On 11/29/22, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry into facility, Upon entry, LPA explained the purpose of the visit with Licensee and Administrator Donald Hay.

Facility has a Covid-19 mitigation plan in place. The designated infection control leader is the Licensee. They have signage on the front door and in the facility requiring masking for all visitors and one central entry point designated for universal entry screening, visitor's log, and a no touch thermometer. Facility follows daily cleaning and sanitation of frequently touched surfaces with disinfectants.

Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. A written Emergency/Disaster plan was posted. Inside of the facility, it was 72 and the hot water was 120 degrees. Centrally stored medications were in locked cabinets.

Multiple deficiencies were observed and recorded by the LPA. However, there was inadequate time to complete the inspection so he will return unannounced on a future date to complete this inspection.