Routine inspection·July 8, 2021

Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/08/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator David Bostanchyan 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 facility 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: surgical mask. Additionally, LPA was screened by facility staff upon entry. LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, staff rooms, bathrooms, laundry room, and outdoor area. During tour LPA observed medications unlocked and accessible to residents in two (2) resident bedrooms. LPA reviewed three (3) residents records and observed that one (1) is not allowed to store their medications, one (1) is able to store medications with assistance and one (1) did not have a completed medical assessment in their file. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. Deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report and appeal rights to be emailed to administrator.