Post-licensing visit·November 17, 2021

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a post-licensing inspection. LPA met with administrator Anita Heydon during today's 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. LPA reviewed 2 of 4 resident files and 2 staff record. LPA reviewed medications of two resident comparing with Centrally Stored Medication Record and physician orders. LPA observed administrator is pre-pouring her medications 24 hours in advance. Resident files were found to be complete and current. Due to time constraints, LPA will return on a later date to finish inspection. Exit interview conducted.