Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met administrator and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; facility administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by administrator.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. There is an outdoor activity space with shaded areas. LPA and administrator completed the full care tool and facility was found to be in substantial compliance at this time.

LPA observed hot water temperature was measured at 117.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire Extinguishers were inspected on 9/13/22 and in compliance. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed centrally stored medications locked up in medication rooms. LPA reviewed two (2) resident and two (2) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left with administrator.