Follow-up·November 18, 2021

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue 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. Additionally, LPA was screened by staff upon entering the facility. LPA toured the facility and inspection 4 resident rooms, 2 bathrooms, garage area, backyard, kitchen and common living spaces. LPA observed the garage area, and saw it is only used as a storage area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA reviewed 2 of 4 resident files and 2 staff record. LPA reviewed medications of 2 resident comparing with Centrally Stored Medication Record and physician orders. Resident files were found to be complete and current. LPA observed the following posted in each resident room: Resident Council Rights, See Something Say Something complaint poster, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LPA observed the following deficiencies: Administrator is pre-pouring medication over 24 hours in advance. Administrator did not transfer caregiver fingerprints from sister facility to this facility. Deficiencies cited on 809-D. Exit interview conducted and appeal rights given.