Routine inspection (multi-day)·March 28, 2024

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct an annual inspection- continuation visit. The LPA was greeted by staff. The LPA informed them of the reason for the visit. Staff contacted the Administrator on the phone and stated that they would arrive shortly thereafter. LPA Urena resumed the inspection by conducting additional physical plant inspection. RECORDS: Records review began at 10:50 a.m., 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 12:30 p.m.; medications are centrally stored and locked in a cabinet in the garage/office area; 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 : 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 LPA reviewed pertinent documents to the annual inspection. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.