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25 | On 10/11/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Manager Jasmin Burns and announced the purpose of the inspection. Administrator certificate is current with expiration date 2/3/2025.
During the inspection, LPA toured the facility inside and outside. Exits and passageways were clear and free from obstruction. Smoke detectors, carbon monoxide detectors, and fire extinguisher were present and operational. LPA reviewed facility Emergency and Disaster Plan. Common areas were clean, odor free, adequately lit, and provided comfortable seating for all residents. The facility was at a comfortable temperature and the thermostat read 76 degrees Fahrenheit. Chemicals, detergents, and cleaning supplies were secured in locked cabinets. The facility had an adequate supply of clean linens and blankets. LPA observed a sufficient supply of personal protective equipment and reviewed facility infection control practices to meet requirements. LPA observed a sufficient supply of perishable and nonperishable foodstuffs. Refrigerator and freezer were clean and food items were stored and marked properly.
LPA toured resident bedrooms and bathrooms. Bedrooms and bathrooms were clean, odor free, and had required minimum furnishings. There were three residents receiving hospice care services at the time of inspection. Bathrooms had required secure grab bars and non-skid mats, and water temperature was within acceptable temperature range. Resident medications were secured in a locked cabinet in the kitchen area. LPA reviewed three residents' medications and medications and medication administration records, and medications appeared to be administered properly. LPA reviewed a sample of staff files and all resident files: required records were present in resident and staff files.
No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted. |