Facility Evaluation Report

On 7/16/2024, Licensing Program Analysts (LPAs) K. Kaur and K. Brown arrived unannounced at the above facility to conduct an Annual Inspection. LPAs introduced selves, stated the purpose of the visit and met with Executive Director Katrina Sinift

LPA conducted facility tour with Administrator. LPAs observed required posting. All pathways, entrances and exits were clear from obstruction. LPA toured locked office storage rooms, and laundry rooms. LPA observed facility common areas which were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. At 10:34 AM LPA observed cleaning solution in cabinet in the dining area. The kitchen was observed clean, in good repair with necessary items and appliances. At 10:46 AM LPA did not observe 7-day supply of nonperishable food. 2-Day perishable foods observed. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. At 11:44 AM LPA observed in Room 221 Block of knifes on kitchen counter and Chemicals and cleaning supplies under kitchen sink. Fire extinguishers observed throughout the facility with service date of July 8, 2024. Bathrooms were properly equipped with non-slip mats and grab bars. Carbon monoxide detector tested and operational in two hallways. Memory care toured with dining area/ Kitchen; several rooms toured. Residents observed with several caregivers in commons areas assembling puzzles. At 11:19 AM LPA conducted a medication audit of memory care resident and did not observe residents’ response to PRN medication. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured main outside Patio from dinning room which was observed with seating and shade. At 12:28 PM LPA observed unlocked gardening tools.

Cleaning supplies and chemicals are kept locked maintenance room. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified.