Facility Evaluation Report

On 2/20/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by Administrator Marifel Ivers and granted entry after stating the purpose of the visit.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for four (4) residents. Currently, there are two (2) Hospice residents present during today’s visit.

This is a single story with a two-car garage facility. The facility has four bedrooms, (three resident rooms & one staff room) and two full bathrooms.

At around 9:23 AM, LPA conducted a tour of the physical plant accompanied by Administrator Marifel Ivers, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were observed during the visit. Bathrooms had operational water Basin. A comfortable temperature of 66 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has two fire extinguishers which are fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).