Routine inspection·August 27, 2021

Licensing Program Analyst (LPA) Dina Alviso, arrived unannounced to conduct an Annual Required inspection and met with Assistant Administrator Sandra Ambrecht. The inspection is focused on the Infection Control procedures and practices of this facility. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Mitigation plan was approved by the Department on 7/12/21. Fire clearance is approved for six (6) non-ambulatory; Fire Department was out on 7/12/21 and did the yearly inspection, facility passed per the fire department report. Fire extinguishers were tagged and serviced as required-8/9/21.There were 6 residents in care at the facility during this inspection. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection. No deficiencies found in the areas inspected. Exit interview conducted with the Administrator.