Routine inspection·January 19, 2023

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/19/23 to conduct a Annual 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 the Department's required COVID-19 protocols, LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical 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. Administrator arrived at the facility. 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, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time. LPA discussed and advised regarding: Use of Guardian to ensure all staff are associated, PRN authorization and documentation as needed, care plans up to date and address restricted health conditions as needed, gates repaired to operate well after storms, report catastrophic events such as power outages, maintain records of emergency drills and review and update emergency plan as needed at least annually. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.