Post-licensing visit·November 1, 2022

Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to conduct a required annual. LPA met with , Administrator on call arrived to the facility. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA toured the interior 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. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time. LPA reviewed 2 resident files and 1 staff file. LPA advised Staff and Resident files be on site and complete, FIT test employees who may work with Covid residents, maintain fire drill records on site. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided to Administrator.