Facility Evaluation Report

On 8/28/25, at 10:00am Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unannounced met Cheryl Boehme and Nataliya Regan to explain purpose of the visit to conduct an annual inspection. Jackson hills assisted living llc is a 70 bed facility with a current census of 61, they are accepting clients over 60, with the restricted conditions of diabedes and dementia for which they have facility wide waivers.

The Facility plant was inspected including the bedrooms, bathrooms, kitchen, storage areas, exteriors, and evacuation routes. The Facility is clean, traffic areas are well lit and unobstructed. Bedrooms have all the required furniture and furnishings, feel very lived in and comfortable. Bathrooms have functional hardware, water temperature is in adequate deliverable range of temp. storage areas are adequately locked for sharps, medications and toxics, proper supervision is provided when unlocked for the risk to dementia care residents. MAR is not totally congruent with the kind and quantity of medications for the residents, addressed as part of the complaint. Food service is not prepared with prevention mechanisms to relive dust and other potentialy hazzardus particles while there is a renovation taking place during the meal service, address as part of the complaint.

LPA observed 2 bedrooms have to access another bedroom to get to thier designated bathroom. It would appear to be every exterior facing bedroom is set up that way. LPA will cross report to fire code to double check it.

LPA observed meds are currently being prepoured for medication service and the facility is trying to get more uptake from the residents to switch to a blisterpack version of thier medications.

LPA observed some residents keep medications in thier own rooms stored in a way that would be accessible to wandering dementia folks in care, the facility will provide some kind of alternate storage solution(lockable boxes/lockable drawers/ect) to keep the wandering dementia folks safe from consuming those.