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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Kylie Whitaker, Administrator, and explained purpose of inspection. Also present was Julia Wihl, Business Office Manager (BOM). The facility is licensed for (48) total residents, (40) of whom may be non-ambulatory and (8) may be bedridden. All residents have a diagnosis of Dementia. There is an approved hospice waiver for 20 residents. Currently there are (14) residents on hospice.
LPA, Administrator and BOM toured the interior and exterior of the facility including several resident rooms with a private or shared bathroom, medication room, dining room, main kitchen, activity rooms, salon, kitchen, and common areas. LPA observed the facility to be clean, in good repair, odor free and the bathrooms to have required supplies, including 20-second hand-washing posters throughout. There is sufficient 2+day perishable and 7+day non-perishable supply of food. LPA observed multiple activities taking place throughout the inspection. Daily menu is posted as well as monthly activities calendar. Fire extinguishers are placed throughout and were last serviced 2/2/2024. Inside temperature measured 75*F. Hot water was tested in (2) resident rooms and a resident bathroom and measured 109*F, 112*F and 114*F. Toxins and medications are secured. There are sufficient linens, towels, blankets and paper products, including PPE and incontinent supplies. Required postings are in the common areas. There is an enclosed outdoor patio and approved egress exit doors. An updated license was printed today to accurately reflect the number of approved non-ambulatory and bedridden residents.
LPA reviewed (6) resident files and found them to be organized and contain current physician reports and care plans. Medications were reviewed for (2) residents, and there were no errors noted. The facility uses an electronic tracking system to manage medications. LPA reviewed (6) staff files. Files were organized and contain current training documentation. Staff complete initial and ongoing required training through an approved on-line vendor. First Aid/CPR was current also. An updated copy of LIC308, LIC500 and liability insurance was obtained. Annual licensing fees are due by 11/23/24 to avoid a late penalty. There were no deficiencies observed. Exit interview. Copy of report provided to Administrator. |