Facility Evaluation Report

Licensing Program Analysts (LPAs) Jessica Cho and Edward Tapia conducted an unannounced required annual inspection in this facility focusing primarily on the Infection Control. LPAs were greeted and granted entry by Executive Director/Administrator (Admin) Geno Koehler after completing the Coronavirus 2019 (COVID-19) screening procedure. Facility screens and documents temperature for all staff and visitors electronically. The PUB475 See Something, Say Something poster was observed in the size of 11"x14" by the front desk. LPAs did not observe the required Department postings as they were currently being replaced. The Administrator's Certificate for Geno Koehler expires on 7/22/2022.

Around 9:38 am, LPAs toured the interior and exterior portions of the facility with Admin Koehler. The facility is a two level structure and licensed for two hundred thirty non-ambulatory residents; approved for secured perimeter and delayed egress; and has a hospice waiver for twenty residents. Currently, there are one hundred and sixty seven residents and fourteen out of the one hundred sixty seven are in hospice care as of today. Facility appeared clean and sanitary in all areas observed. LPAs inspected sixteen randomly selected rooms total- eight on each floor and observed the following: all sixteen rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms tested operational. The bathrooms were observed to be in good repair except in Apartments #141, #145, and #259 as a single light bulb in each of the bathrooms needed to be replaced. All bathrooms were provided with grab bars and non-skid floor mats, and hot water measured between the ranges of 109.5 to 116.6 degrees Fahrenheit. LPAs observed hand washing signs in the community bathrooms but none in the resident's bathrooms. Facility had hand sanitizers mounted on the wall throughout the facility and in the common areas. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. Fire extinguishers were mounted and charged. For the exterior portion, LPAs observed patio furniture under a gazebo in the courtyard, and the grounds were free of tripping hazards.