Facility Evaluation Report

Licensing Program Analyst (LPA) Rankin arrived at 8:40 a.m. to complete the 1-year annual visit to the facility above. LPA met with Megan Drap, Business Office Director and Designee and explained the purpose of the visit. LPA additionally collected documents for complaint # 29-AS-20260402125617.

Physical Plant & Environment Safety: LPA toured the Memory Care (MC) community. Resident rooms and bathrooms were observed in good condition, with operational fixtures, secured grab bars, and non-skid shower surfaces. Cabinets were locked, and disinfectants and cleaning solutions were inaccessible to residents at the time of the visit. Areas requiring lighting or minor maintenance were discussed with the Memory Care Director. The MC unit has secured, coded entry with delayed egress. During the visit, staffing consisted of 2 caregivers and 1 medication technician. The patio and courtyard areas provide adequate outdoor space and shade.

Incidental Medical & Dental: Medications stored in the MC medication cart were reviewed. Documentation is completed in the electronic Medication Administration Record (MAR) and the Centrally Stored Medication and Destruction Record (CSMDR). LPA reviewed 3 PRN medications for 2 residents and identified incomplete PRN documentation: Resident 4 (R4) had 13 of 28 doses not recorded, and Resident 5 (R5) had 6 of 11 doses not recorded. A citation was issued.