Facility Evaluation Report

Unannounced Post Licensing visit made out to this facility on 01/18/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Cleo Brelin. A brief interview was conducted with the facility designated Administrator at this time.

It was learned that there weren't any residents under the care of hospice at this time.

This facility does have a hospice waiver to be able to accept and retain up to (6) hospice residents at any given time.

It was learned that there were (2) residents diagnosed with dementia at this time.

It was learned that there were (2) residents under the care of home health at this time.

Living area, dining area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

Kitchen area was toured. Cabinets and drawers were reviewed. Knives and other sharp objects were observed to be locked and made inaccessible to the residents at this time.

Food supply was reviewed to make sure that there was a sufficient amount of 2-day perishable and 7-day nonperishable quantities at all times.

Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures for handling, dispensing, and documentation of the resident medications was discussed with the facility designated Administrator. Dispensing log was also reviewed along with the Medication Administration Record.

A tour of the resident bedrooms was conducted. Furnishings and furniture were observed to be sufficient and maintained in compliance at this time.

A tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees at all times.

Grab bars and non skid mats were observed to be present and in good repair at this time.