Facility Evaluation Report

On 06/18/24, 9:15 AM Licensing Program Analyst (LPA) Raymond Comer, conducted a scheduled pre-licensing inspection of the Facility. LPA met with Administrator, Matt Ryan.

Facility is licensed as a two-story building with resident bedrooms, private bathrooms, and multiple public bathrooms. Fire clearance approved for (75) non-ambulatory, and an additional fifteen (15) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, there are fifty-two (52) Ambulatory residents, eight (8) Non-Ambulatory residents, none of which are bedridden, and seven (7) residents receiving hospice care services.

LPA and the Administrator toured the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit access point, with three (3) emergency exits being located off the dining room area, and two stairwells. Emergency exit routes are clear of obstructions. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Facility is separated into Assisted Living and Memory Care floors. LPA observed the delayed egress system working properly. Room temperature is comfortable; wall thermostat displays a setting of 73°F., within the required range.

The facility maintains required Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/30/2024 .