Routine inspection·October 12, 2022

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on10/12/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, 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 and contacted licensee 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: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Geta "Laurie" Pop arrived to assist with the inspection. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and licensees followed the infection control domain guidelines and facility was found to be in substantial compliance at this time. Records and staff review found that as of 10/8/22, in response to previous caregivers unexpectedly quitting, the two (2) staff working, S1 and S2, were hired before receiving criminal record clearance. Citation and civil penalties are applied. The caregiver are temporarily replaced with staff from another RCFE and transfer request was submitted. LPA reviewed R1's file and it was complete. LPA and licensee discussed signed medication orders and PRN Authorization letters Licensee received a copy of liability insurance certificate . A Deficiency and civil penalties are being cited as a result of todays inspection for criminal record clearance. Exit interview conducted and copy of report and appeal rights left at the facility.