According to the facility’s license, the facility has a maximum capacity of sixty-four (64) clients, thirty-nine (39) of whom may be non-ambulatory, twenty-five (25) of whom may be bedridden. Hospice waiver for twenty-five (25). Approved delayed egress/secured perimeter. During today’s inspection, there were a total of sixty-three (63) clients in care.

LPAs Kane and Rodgers, accompanied by Executive Director Carlborg, toured the interior and exterior of the facility, and inspected several rooms. 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 and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 73 F. Hot water temperature at taps accessible to clients were all compliant.

Refrigerator and freezer temperature were compliant. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility.

LPAs interviewed/observed staff and residents. LPAs reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas.

LPAs observed residents in the common areas engaged in their daily routines and activities. Residents appeared well-supported by staff and comfortable in their surroundings.

An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.