Facility Evaluation Report

Licensing Program Analysts (LPA) Sarah Hurt and Brianna Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Brittany Kavanaugh, Continual Administrator's Certification expires 02/22/2028. There are currently 73 residents who reside at this home and there is 6 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The facility performs disaster drills as required. Water temperature was tested in multiple rooms to be between 105 and 120 degrees. First Aid kit is on site and complete.

LPA's reviewed a sample of staff and residents files, facility Plan of Operation, Emergency Disaster Plan, and Infection Control Plan.

Resident 1 and Resident 2's pre admission appraisal is not completed. Resident 3's updated Needs and Services appraisal (in house form RCFE Home Health & Hospice Service Plan) is not complete. Resident 4's Admission agreement does not document accurate amount to be paid, admission agreement amount is $4,800, and charged amount is $1,000. Resident 5 is on a special diet that is not being followed. Resident 5 has over the counter medications accessible in bedroom despite Physician's Report documenting they are not able to manage own medications, Resident 5's medications are not documented correctly on Centrally stored medication record.