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25 | At 8:00am on 02/04/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Administrator, Vanetina Roberts, announced who he is and the reason for the visit. LPA reviewed staff roster and cleared all 3 care staff that were working at this facility. LPA conducted full Staff and Resident file reviews, LPA reviewed facilities Emergency Disaster Plan, Infection Control Plan and Medication Administration Records (MAR) and Centrally Stored Medication Records (CSMR). LPA reviewed facilities Plan of Operation (POA) including Dementia requirements and Bedridden requirements as outline in facilities POA. LPA noted that no citations or violations were noted during the documentation reviews.
Administrator and LPA conducted a facility tour LPA noted that the facility is a 6 bedroom, single resident occupancy, 3 shared bathrooms, two living rooms, 2 dining rooms, a kitchen. There is a large back yard with a room for seating and a covered patio for shade so that residents have access to outside activities and visits. LPA noted that the medications are locked in a medication cabinet located in living room 1. There is a regulations completed !st Aide kit located in the medication cart. LPA observed at least 2 days of perishable foods and at least 7 days of nonperishable food for 6 residents and staff. LPA observed emergency food supply in the garage for more than 72 hours of supplies. LPA noted that the are fire extinguishers that are primed and in the green reading, LPA noted that all rooms have duel, smoke and carbon monoxide detectors that are hard wired and battery. LPA noted that the facility has a sprinkler system with a fire pull located in the hallway. LPA observed that water pressure to the sprinkler system to be at 77 lbs. which is located at the front of the facility. LPA noted that all exits were free of obstructions and obstacles. LPA noted that the facility is clean and in good repair. LPA noted that no citations or violations were noted during the physical tour of the facility.
Administrator and LPA conducted a full review of the annual care tools modules. LPA noted that there were no citations or violations during the care tools modules review. LPA noted that there are no citations of violations as a result of the facilities full annual inspection review.
Exit interview, report read, and report provided. |