Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Brenda Myers, Interim Executive Director, and LPA explained the nature of the visit. Facility is licensed for 92 ambulatory, 120 non-ambulatory residents, of which 8 may be bedridden. Facility has an approved hospice waiver for 25 residents. Delayed egress doors for memory care only. There are 10 residents on hospice during today's visit. This facility consists of two main areas. The assisted living and the memory care unit which are protected by delayed egress exits.

LPA Martinez along with the Interim Executive Director toured the physical plant of both the assisted living and the memory care unit. LPA observed a bistro adjacent to the main dining room where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has 2 medication rooms on the memory care unit and on the 2 nd floor. LPA inspected both locations and LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. Resident bedrooms had the required