Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Patricia Hounsell and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap at hand washing stations (residents use cloth hand towels which are single-use), and tight-fitting lids on trash cans.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 111.3 degrees. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed a knife block in the kitchen which contained numerous knives which could be a danger to residents. Deficiency cited. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. The facility has an in-ground pool which LPA Colvin observed to be gated and locked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed that though the facility has residents with Dementia, they do not have auditory alarms on the exit doors. Deficiency cited.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents. Facility has a hospice waiver for 2 residents.