Facility Evaluation Report

At approximately 8:30 am, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. Upon entry, LPA Campbell observed residents going in and out of the entrance of the community mall area. Once LPA Campbell identified themselves, staff notified the administrator. Once the administrator arrived, LPA Campbell explained the purpose of the visit and the administrator stated they would find a meeting room available for LPA Campbell's use. Once a meeting room was found, LPA Campbell requested a list of residents and staff to select from for a random file review.

The facility is licensed to serve 277 residents. Of those residents, 15 of them may be hospice residents. The facility has delayed egress and a dementia unit for 30 residents. Each resident room has its own bathroom and temperature control. LPA inspected the physical plant including but not limited to kitchen, bathrooms, and activity areas. LPA Campbell observed that there was sufficient furniture and lighting throughout the facility.

LPA Campbell measured the water temperature for two rooms. One was inhabited and the other vacant. When testing the water in the vacant room, the hot water side was labeled incorrectly The administrator stated they would contact maintenance to make the correction. During a tour of the kitchen, LPA Campbell observed sufficient seven day non-perishable and two day perishable food supplies. Items in the freezer and refrigerator were covered or sealed.