Follow-up·August 9, 2022

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/9/22 to conduct a Case Management Inspection. LPA met with staff and explained the purpose of the visit. Prior to initiating the visit, 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 licensee. 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: N-95 mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior of the facility . In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Executive Director (ED), Price discussed the facility's plans to no longer pursue building modifications to increase non-ambulatory capacity due to prohibitive costs. Licensee will continue fire watches as agreed to until there is one non-ambulatory resident remaining. There are currently 5 non-ambulatory residents. ED provided LPA with requested documents. Licensee will continue to update CCL. Licensee and ED agreed to update the facility's administrator designee. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.