Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 9:30am to conducted a 1 year annual visit to the facility above. LPA met Administrator Jodi Beltrama and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Infection Control: The facility has submitted an Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) on hire and annual there after.

Physical Plant & Environment Safety: The facility is a 59 bedroom with 59 private bathrooms and 3 common areas restrooms currently occupying 62 residents and employs 42 staff and 1 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors and sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The facility has a signal system in each residents room. The pathways are clear of any obstruction.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 7 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Staff handling medications had initial and/or annual training of 8 hours of medication training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, some staff had food handler certificates. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health care plans had training records on file.