Facility Evaluation Report

Unannounced Plan of Correction visit made out to this facility on 01/17/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Cleo Brelin. A brief interview was conducted with the facility designated Administrator at this time.

The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 01/09/2025. This visit was to follow up on the Plan of Correction that was due.

The following deficiencies were observed and cited on 01/09/2025:

Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:

When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled.

Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interview