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25 | Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Justin Webber. According to the facility’s license, the facility has a maximum capacity of 511 non-ambulatory residents, of which 370 may be bedridden with a hospice waiver for 15. The facility has one large main building, multiple cottages and a delayed egress memory care unit.
LPA toured the interior and exterior of the facility and inspected multiple rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were measured all between 110 degrees F to 117 degrees F. The facility does have a pool with appropriate locked fencing. LPA tested multiple resident call buttons and verified signal system was in working order.
LPA toured and observed the commercial kitchen and walk-in freezer/refrigerator. The kitchen was clean, organized and sanitary. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food.
LPA observed multiple medication rooms and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. LPA reviewed care staff first aid refresher training's within the facility training system. Per Executive Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible on each floor.
No deficiencies were cited on todays visit. An exit interview was conducted with Executive Director Justin Webb, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit. |