Facility Evaluation Report

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director Wes Lavender. The facility's license shows a maximum capacity of 175 elderly residents, age 60 and above, 30 of whom may be bedridden on the first floor only. Hospice care waiver is approved for thirty (30) residents. Facility is equipped with delayed egress and secured perimeter in the dementia unit. During today’s inspection, there were 151 residents in care.

LPA accompanied by Executive Director Lavender toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. The pool located on the premises was fenced and locked. Per Executive Director Lavender, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.