Facility Evaluation Report

At approximately 10:55AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Legal/Non-Compliance visit and to follow up on an incident report submitted by the facility. LPA met with Interim Administrator Lucy Russell, toured the building and reviewed records.

The following areas of non-compliance were addressed today:

LPA reviewed staff training and observed all staff have recently received training in residents personal rights and another is scheduled for next month. Administrator informed LPA they will ensure new employees receive all required training in the first 4 weeks of employment and will have refresher personal rights training throughout the year.

LPA verified that all staff employed at the facility have a background clearance and are associated to the facility. LPA verified there are no staff or other individuals other than residents, living in the building.

LPA reviewed records and observed the facility has been submitting unusual incident reports as required.

On 04/18/2026, staff entered residents, R1, room and found them eating barrier cream. R1 had the cream on their chest and tongue. Staff assisted with cleaning up and ensured the cream was removed. LPA reviewed residents file and observed there were no previous issues with hygiene products and no indication on the physicians assessment that resident was at risk. Facility updated the care plan and changed procedures to ensure hygiene products are not accessible. All notifications were made within timelines.

No citations issued during today's visit.