Routine inspection·May 7, 2024

Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Executive Director Jennifer Heldoorn. LPA explained the nature of today's visit. LPA accompanied with MS Heldoorn , conducted a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at resident bathrooms are within regulation. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were tested by the Fire Department and found to be in working order. Inspection document was obtained. Facility sprinkler and kitchen sprinkler / extinguisher systems were tested and found to be in working order. Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. Kitchen is well staff and aware of resident's specific dietary needs. Kitchen area is clean and sanitary. Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. The facility is appropriately staff during night shift hours Record Review: LPA requested and reviewed (7) resident and (5) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA reviewed client files for admissions agreement, physician report, and needs and service. Administration: LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation. Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions. No deficiencies cited. An exit interview was conducted where this report was provided and discussed with MS Heldoorn.