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25 | Licensing Program Analysts (LPAs) Amy Rodgers and Patrice Bazemore conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Executive Director (ED) Mark Ranno. The facility's license shows a maximum capacity of 184 non-ambulatory residents, ages 60 and above, it is approved for 32 bedridden and 23 in hospice waiver. Facility is equipped with delayed egress and secured perimeter.
LPAs and ED toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required. The facility has a pool that was locked and inaccessible to residents. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients, and reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas.
(continued on LIC809C)
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