Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Executive Director (ED), Eugenia Smith.

LPA toured Generations (aka Memory Care) with ED to include 6 apartments (RM 119, 201, 204, 111, 114, and 115), bathrooms, activity room, dining room and kitchen. 6 apartments equipped with beds, linens, chairs, dressers, night stands and adequate lighting. LPA observed 2 residents who uses oxygen. Oxygen in use sign posted outside of resident apartments. Temperature in Generations observed between 72 - 76 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. No observations of chemicals, sharp objects, or items which could pose a danger that are accessible to residents in care. LPA reviewed 4 resident files in Generations. 4 out of 4 resident files contained an updated medical assessment, TB result, service plan, emergency/contact information, admission agreement, safeguard of personal property and valuables, and personal rights form. LPA observed the residents who are using oxygen and half rails contained physician's orders on file. LPA reviewed 4 residents centrally stored medications and centrally stored medication records. Resident (R1)'s medications were counted and observed with extra dosages of medications for 4 bubble pack medications. Facility was unable to track where the discrepancy had stemmed from as the electronic MAR shows that staff had signed off on the administration of the medications daily.

LPA entered the kitchen with ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 36 degrees Fahrenheit. Items inside the refrigerator observed covered and labeled. Freezer temperature maintained at 0 degrees Fahrenheit. SEE LIC809-C.