Facility Evaluation Report

On 4/8/2025, Licensing Program Analysts(LPAs) Noel Wolf Petersen and Michael Bilger arrived unannounced to perform the 90-day post licensing visit. They were met by administrator Rachelle Reyes. The LPA requested and reviewed five (5) staff files, and found evidnce fingerprint clearance and first aid/cpr training. The required trainings are present, LPA interviewed 5 staff at random to assess their knowledge of the required actions and found no deficiency.

The facility is a RCFE 134-bed facility with 64 clients currently, no bedridden, some on hospice.

The physical plant was inspected. No bodies of water were observed. Fire alarms, Carbon monoxide alarms, first aid kit, door alarms were functional. The average response time to their alarm pager system was 2 minutes 53 seconds. The fire extinguisher was last checked 9/12/24. The field inspection included but was not limited to, the residents bathroom, residents bedroom, kitchen, open recreational spaces, the outside. Evactuation routes were free of obstruction and in good repair. The sharps and toxics were in locked and away from the residents in care. The facility has adequate perishable food for 2 days and nonperishable food for 7 days. All food is within its best by date.

The required posters, ombudsman, personal rights, federal workers rights, theft and loss, and evacuation plan were up and available to residents. The facility was found to be largely in compliance.

The report was read and delivered to the facility representative.