Facility Evaluation Report

On 3/26/2025 LPA Tryon visited the facility to conduct a required annual visit. LPA met with Executive Director Patty Uclaray. The facility currently has 58 residents.

LPA toured the facility with Ms. Uclaray including common areas, resident rooms, bathrooms, kitchen, dining area, food storage, hallways, medication rooms, storage for potentially hazardous items and materials, laundry room. The facility is clean and well-furnished, resident rooms were clean and had appropriate furnishings. Food supplies appeared to be well-stocked to meet the requirement of 2 days perishable and 7 days non-perishable. Food was stored appropriately to maintain freshness. Lunch appeared appealing and appetizing. A new dining management company took over the kitchen in February and is running all the kitchen operations. It is going well so far. Residents have spoken up and said the menus are too "fancy", but the company is responding and making changes. There is a monthly dining committee that meets regarding these issues.

Medications are centrally stored and locked. Facility keeps centrally stored logs. Logs are on computer; and back-up binders. Controlled substances are double-locked in the medication carts. Chemical storage was viewed, cleaning chemicals are stored in a locked metal cabinet.

Hot water is within appropriate temperature range. The building has a fire alarm/sprinkler system that is checked regularly. Fire extinguishers present and charged.

LPA reviewed the CARE Tool with Administrators. LPA interviewed 1 staff and 1 resident, reviewed 5 resident charts and 6 staff charts.

LPA requested copies of current liability insurance proof, administrator certificates.

At this time the facility appears to be in substantial compliance with the regulations. No deficiencies cited.