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25 | At 1:20pm on 12/16/2023, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the annual facility inspection. LPA also delivered final findings to a complaint of this facility on a separate report on this date.
LPA toured facility with Administrator. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning and are hardwired throughout the facility. Fire extinguisher was fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 70 degrees F. Hot water temperature tested within regulation parameters of 105*-120* (f) . Residents’ rooms are appropriately furnished with adequate lighting and linin. LPA observed more than two days of perishable and more than seven days of non-perishable food. A written disaster and mass casualty plan is readily available located in the facility kitchen. Infection control plan and emergency disaster plan were reviewed by LPA and Administrator. LPA conducted a sample medication audit and Centrally Stored Medication Records review (CSMR). LPA noted that the facility was clean and in good repair with no obstruction in the hallways or any exits/entrances. LPA noted that no citations or violations were discovered during the full facility walking tour.
Administrator and LPA conducted a full review of the annual care tools module. LPA noted that noted that no technical, violation, or citations were issued as a result of the full review of the annual care tools modules. LPA noted that the full annual facility inspection there were not violations or citations issued.
Exit interview, report read, and report provided. |