Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the required annual inspection. The initial visit was conducted on 07/27/23. LPA met with Robert Barton (Executive Director) and discussed the purpose of today’s visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and completed the following domains:

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Robert Barton expires 01/31/25. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) through Staff #7 (S-7). Pertinent staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training.

Resident Rights-Information: Resident rights are posted and included in Resident files. Let-Us-No poster posted. LTCO poster posted.

Resident Rights-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #8 (R-8). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

Refer to LIC 809C for the continuation of this report.