Facility Evaluation Report

Licensing Program Analysts (LPA) Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct an annual inspection continuation. LPA's explained the purpose of the visit and met with Administrator Linda Poythress.

LPA Doucette toured the facility with the Administrator. LPA found resident rooms to be clean. LPA took a sample of resident rooms water temperatures in memory care and assisted living, which measured from 111 F to 124.6 F. LPA observed a 2 day perishable and 7 day non perishable food supply.

Facility has an activity room. Cleaning supplies were observed to be locked. Medications were locked in a medication room in a locked medication cart.

Facility has outdoor seating for residents in the outdoor courtyard.

LPA's Doucette and Miranda reviewed medications. LPA's found medication errors for R1 and R4. R1 missed 6 days of R1's medication. LPA found errors in the centrally stored log for R4, log shows on future date of 1/11/25. LPA's took photos. Facility does not have documentation of a licensed professional reviewing the faclity medication management program and procedures for the facility.

Fire extinguisher was last serviced May 2024. Facility has sprinkler system and pull station fire alarm. Facility does not have an emergency disaster plan completed to meet regulations. Facility has not conducted an emergency drill. Facility does not have emergency numbers posted.

LPA Miranda reviewed staff files. Staff have current CPR first aid training. Facility staff do not have any other training that meets regulations.