Routine inspection·October 21, 2024

On 10/21/24, 10:15 am , Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Administrator Designee; Wellness Director, Nancy Adams , and reason for the visit was disclosed. Facility is licensed as a two story building. Fire clearance approved for seventy-two (72) non-ambulatory, and twenty-eight (28) ambulatory, for total capacity of one hundred (100) residents. Bedridden cleared for bedrooms #101-#107, #109, #111, #113, #115, #117, #119, #120, and #122. Hospice waiver approved for twenty (20). Currently, five (5) residents receiving hospice care services and no bedridden. At 10:30 am, LPA conducted a tour of the physical plant with the Administrator and observed the following : Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 77.0°F . within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted: September 25, 2024. [LIC 809C] Continued Kitchen: At 11:15AM, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are secured, and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near any food areas. Resident records: A total of six (6) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator Designee, Nancy Adams.