Routine inspection·September 21, 2021

Licensing Program Analyst (LPA) Kristin Kontilis conducted an onsite one-year infection control annual visit to the above-named facility. LPA met with Timothy Pryko, Administrator and explained the purpose of the visit. LPA conducted a physical tour of the facility. The facility has submitted a Mitigation Plan to the Department. The facility has an entry station at the front of the building. Upon entry, staff, visitors, and residents returning from an outing are required to sign-in, complete a symptom questionnaire, and have a temperature screening. All documentation is kept in a a binder on a daily basis. The entry station has PPE gear, hand sanitizer, and disinfecting wipes along with a thermometer. Entrance interview conducted. There are currently 6 residents residing in the facility. The facility is home to residents with a dementia diagnosis. There are currently three (3) residents on hospice. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on 9/01/2021. The backyard has a covered patio with outdoor furniture and sitting areas. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked private staff room is located in the main part of the house near the front entrance. The living room and dining area are neat and clean. The facility maintains a comfortable temperature at 75 degrees Fahrenheit (F). Hallways, bedroom doors and walls are in good repair. Please continue to 809-C, Pg 2.. The facility has 6 private bedrooms. Bedroom #1 has a shared bathroom off the hallway. Bedrooms 2-6 each have a private bathroom. Each resident’s room is furnished with overhead lights to provide sufficient lighting, a nightstand, and a bed. The bathrooms have secure grab bars and no skid flooring. Exit interview conducted. Copy of report emailed. No deficiencies noted.