Routine inspection (multi-day)·July 11, 2023

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a CASE MANAGEMENT Continuation Annual inspection. The LPA met with Executive Director (ED), Abigail Trexler , and explained the reason for the visit. On 06/27/2023, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA met with Executive Director (ED), Abigail Trexler, and explained the reason for the visit. During today’s inspection the LPA conducted records review at 11:00 a.m. RECORDS: Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in carts in the Wellness Center located on the second floor and first floor; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL : Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control. The LPAs obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster No deficiencies were cited at this time. Exit interview conducted with facility representative. A copy of the report was issued.