Facility Evaluation Report

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year required/annual visit. LPA met with the Executive Director Danielle Barry and explained the reason for the visit. Census:84

The facility is licensed for a capacity of 135 Non-ambulatory residents of which 20 may be bedridden. Hospice Waiver approved for 25.

LPA Lund and Executive Director Danielle Barry toured/inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The most recent emergency drill was conducted on 8/1/24. LPA observed 2-day perishables and 7-day non-perishables. Facility utilizes a wander guard system for residents in need of more assistance. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was continuously observed to be at 73*F throughout the facility which is within the required range of 68-85*F. LPA obtained information that the facility houses 4 water heaters. The hot water temperature was measured between 106.5*F and 112.3*F in a random six residents rooms, which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and pull alarm system in the facility and is in compliance. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 7 staff and 8 resident files during today’s visit and were in compliance. LPA Lund went over the stipulation order and staff are continued to be trained every six months.

No deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.