Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Bridgette Wilinski and explained the reason for the visit. The purpose of the visit is to complete the required inspection.

LPA Trueman toured the facility along with Administrator Bridgette Wilinski today 04/11/2023 at 11:15 AM and the following was observed:

Facility contains 6 Client Bedrooms and 2 Client Bathrooms, dining room, living room, TV room, and activity room.

Annual Inspection includes the following Domains:

Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.

Interviews were conducted with 3 clients and 1 staff (only staff on duty from 8 to 6). 6 client files and 1 staff file were reviewed

Medication was administered per physician's directions.

Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.

Staff responsible for providing care and supervision received training in First Aid.

Licensee maintained an individual admission agreement for each client.

Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.

Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.

Deficiency was observed in the dining room with there being a water leak with paint peeling off the ceiling.

Deficiency cited on 809 D. Advisory Notice issued for not having an Infection Control Plan submitted.