Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance and Annual Required inspection to this facility and met with Executive Director/Administrator Ric Pielstick. There are residents (48 AL and 31 MC) with 4 under hospice at facility. The facility serves residents with dementia and has a plan of operation for special care and programming.

LPA/Administrator toured the facility around and made the following observations: Tour included resident apartments, kitchen, food storage, dining room and various common areas used by residents. Facility was a comfortable temperature and passageways were free from obstructions. Exits in memory care were equipped with delay egress that were working properly during the visit. Fire Extinguisher was found to be last charged on 09/2022 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. Smoke detectors and fire sprinklers are annually inspected June 2023. Most recent fire/disaster drill was conducted June 2023. Resident rooms were furnished per regulation. Water temperature in various sinks accessible to residents in care measured at 115.2, 109.8 (x2), 108.3, 110.8, 114.3, 113.1, 115.3 and 114 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets as well as mobile housekeeping carts. Dangerous items were observed locked and not accessible to residents in care. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality, stored per regulation and there are residents with special diets needs that are been provided by the facility. Facility kitchen has a binder and posted on the wall with all resident’s names, pictures, and their needs. Food is available for residents any time of the day. Medications were centrally stored, locked in medication room, they were reviewed. There is a daily activity schedule for residents.

At approximate 9:30am LPA/Administrator observed bathroom toilet in room# 124 needed assistance, there were feces on the toilet and bathroom floor. Administrator called staff immediately to clean the bathroom.