Facility Evaluation Report

Unannounced Plan of Correction visit made out to this facility on 07/17/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Nicole Ell. A brief interview was conducted with the facility designated Administrator at this time.

The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 06/13/2025. This visit was to follow up on the Plan of Correction that was due.

The following deficiencies were observed and cited on 06/13/2025:

All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.