Facility Evaluation Report

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) James Arp. The facility's license shows a maximum capacity of 220 non-ambulatory residents, of which 100 may be bedridden. All rooms are approved for bedridden and the facility is approved for delayed egress on floors 2, 3, 4, and 5. Additionally the facility has an approved hospice waiver for 20. During today’s inspection there were 194 residents in care.

LPA, accompanied by ED James Arp and Building Manager John Miller, toured the interior and exterior of the facility and inspected common areas as well as a sample of resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to residents were all compliant. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Kitchen staff demonstrated precautions taken for dietary restrictions. Cooking, dining equipment, and utensils were present. Knives were stored in areas inaccessible to residents.