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25 | Licensing Program Analysts Ryker Heberle and Ravi Patel (LPAs) conducted an unannounced annual inspection on 04/14/2023. LPA met with facility administrators Marlene Elliott and Amber Elliott (Admins).
LPA toured the facility, including living room, kitchen, dining room, 5 bedrooms, 2 bathrooms, laundry room, and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. Facility Infection Control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in May 2022. Smoke/carbon monoxide detectors tested and observed to be fully operational. Facility temperature observed to be 65 *F. Water temperature observed to be 108.1 *F.
LPA inspected resident and staff files. 4 out of 4 resident files were observed to be complete, 2 out of 2 staff files were observed to be complete. LPAs performed an audit of facility medication cabinet. Facility only administers medication to 2 out of 4 residents. 2 out of 2 resident medication trays noted to have all prescribed medication. Medication administration records and lists observed to contain all necessary information. LPAs interviewed 3 out of 4 residents. 1 out of 4 residents was currently at their work program. 3 out of 3 residents interviewed expressed satisfaction with accommodations. 2 out of 2 staff interviewed demonstrated qualification for all duties and responsibilities. Facility to provide copy of mass casualty plan, Admin clarified that the document has been completed, but could not be located during LPAs inspection.
No deficiencies cited during today's visit. Advisory note issued. This report was reviewed with facility Administrator Marlene Elliott & Amber Elliott and a copy of the signed report was provided. |