Post-licensing visit·September 8, 2023

on 09/08/23, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced post licensing visit to this facility. LPA identified herself to the Designated Administrator, stated the purpose of the visit and a brief interview followed. LPA inspected the kitchen and opened all drawers and cabinets. Sharps were kept in a locked drawer. Cleaning supplies were locked under the sink in the locked laundry room and inaccessible to residents in care. Food supply was reviewed for adequate 2-day perishables and 7-day non perishables quantities at this time. Pantry area was reviewed as well for additional non perishable food items. LPA inspected all 3 resident bedrooms and 1 for staff. All had the required furniture, furnishings, and lighting to be in compliance at this time. LPA measured the hot water in the hallway bathroom and it was observed to be 121.4 degrees Fahrenheit. The Designated Facility Administrator lowered the temperature to return to compliance. Bathrooms contained grab bars and non-skid mats. Each resident had their own private bathroom so each had their own towels for personal use. LPA pointed out that when census increases and bathrooms are shared, paper towels should be used instead. An inspection of the exterior of the facility was conducted by the LPA. There were no outbuildings or bodies of water on the grounds. The facility had a covered area with seating for residents to enjoy. The backyard was completely fenced in and in good repair. All window screens were in tact as were the gutters. LPA reviewed medication, medication logs as well as storage, and dispensing procedures. All were in compliance at this time. A file review was completed for the two residents in care. Files were in compliance. LPA provided technical assistance regarding certain forms. Files for 2 employees were also reviewed and found to be in compliance. The final component of this Post Licensing visit was completed with the Designated Facility Administrator. Deficiencies that were observed are cited on the LIC 809 D page. A copy of this report was provided along with the Appeal Rights. Exit interview.