Facility Evaluation Report

On 10/09/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Executive Director Jennifer Gephart where LPA explained the purpose of the visit. The facility has an approved fire clearance to accept and retain 10 residents that are bedridden with an approved hospice waiver for (15), there is currently 14 residents receiving hospice services. LPA conducted a tour of the facility, below is a summary of what was observed.

The facility is a two story structure; the first floor consists of facility's assisted living and memory care with delayed egress. There is an activity room, lounge area and dining room located on the first floor. The second floor will service assisted living residents, and also contains a medication room, theater room, beauty salon, and an activity room. The bathrooms were observed to have grab bars, with pull cords and the signal system was tested and observed to be operable. The hot water temperature was tested in resident bathrooms and found to be within regulatory limits of 106.7 degrees Fahrenheit.

Medications were observed to be labeled and in a locked place that is inaccessible to residents. The facility is utilizing an electronic medication authorization record tracking system. The smoke/carbon monoxide detectors were tested and observed to be operable. The facility fire/safety inspection was completed on 07/10/24. The last emergency disaster drill was conducted on 5/24/24, deficiency cited as drills are to be conducted on a quarterly basis and should have been completed in September 2024. The facility was observed to have fully charged fire extinguishers throughout the facility, that were serviced in May 2024. There are no known guns or ammunition on the premises. There are no pools or bodies of water observed at the facility. The outdoor and indoor passageways are free from obstructions.

Food supply: the facility was observed to have a 2 day supply of perishable food items and a 7 day supply of non perishable food items which meets the requirements