Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Lynn Palin (Director of Social Work) and discussed the purpose of today’s visit. Dan Townsend (Director of Facility Operations) arrived shortly after to assist with tour.

This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are six (6 ) resid ents under hospice care. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – four (4), Cedar Court census – eleven (11), Maple Court/Birch Court census – thirty-four (34), and twenty-two (22) in Southwoods Lodge Memory Care. Southwoods Lodge Memory Care is approved for delay egress. Total census for this facility is seventy-one (71).

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected ten (10) rooms; of which three (3) in Southwoods Lodge Memory Care and seven (7) random rooms in assisted living wing of the facility. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#209. Staff responded 3 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways.