Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a continuation of the required annual visit at 01:07 PM. The LPA met with facility designee Michelle Parr. Licensee/Administrator was unavailable during today's visit. Entrance interview conducted.

During today's visit the following was observed/reviewed:

STAFF RECORD REVIEW: LPA reviewed four (4) staff files for, but not limited to : health screening, TB test, training records and fingerprint clearance. All four (4) staff files observed were in compliance with regulation.

EMERGENCY DISASTER PREPAREDNESS: During today's visit, LPA reviewed the facility's emergency disaster plan. Emergency drills are conducted quarterly, with the last drill conducted on 08/04/2023. Emergency disaster plan was observed to be complete and updated annually, as required.

INFECTION CONTROL: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: During today's visit, LPA interviewed staff and residents.

No citations issued. Exit interview conducted. A copy of today's report was provided.