Facility Evaluation Report

Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA was met by Administrator Tina Healy.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, and was clean and safe for food preparation. Food supply checked, LPA observed a two day perishable and 7 day non perishable. Resident rooms checked. LPA observed an adequate supply of linen. Facility has two water heaters. Hot water measured at 114 and 127.3 degrees F. Facility was set at 72 F. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 06/17/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm and sprinkler system. Last fire drill conducted 7/24/2024. All cleaning supplies are locked and secured in a storage cabinet. Medications were locked in a medication room.

LPA reviewed resident and staff records. LPA reviewed medications. R1 missed a medication on 8/23/24. Facility has a centrally stored log however it does not list a start date. Facility has over the counter medications for residents however residents do not have a PRN order signed by the doctor for the medication. Facility medication technician stated its the "house supply". LPA obtained copies of medication issues.

An exit interview was conducted with the Administrator and a copy of this report with plans of correction and appeal rights were provided.