Facility Evaluation Report

At approximately 11:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Jennifer Hall and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for six residents.

At approximately 11:45AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and outdoor activity space. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food is prepared at the main kitchen and brought in containers to ensure it stays at the proper temperature. Facility has required seven-day non-perishable and two-day perishable supply of food. Emergency food stores and water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. First aid kit was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has not been conducting Emergency drills.

At approximately 12:15PM, LPA reviewed 7 of 20 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a physician visit within the last 12 months was present. Hospice Care plans were present. LPA conducted a review of medications. Medication is locked and not accessible. Continued on LIC809-C…