Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Executive Director Michael Fountain (ED) .

LPA toured Compass Rose (Memory Care unit) with ED to include 4 apartments (RM #129, #126, #123, #120), bathrooms, activity room, kitchen, dining room, and patio area. All fire exit routes were free and clear of obstruction. LPA checked 2 common restrooms in memory care unit. One delayed egress exit door of memory care unit was observed in working condition and the other one was under repair. LPA observed a caregiver sit outside if the exit door of the memory care unit to monitor. Room temperature maintained between 76 degrees F. Kitchen refrigerator temperature maintained at 40 degrees F. Freezer temperature maintained at 0 degrees F. Hot water temperature measured at 118 degrees F. Chemicals, disinfectants, and medications observed locked in Compass Rose. During visit, resident's observed participating in various activities.

2 resident files in Compass Rose was reviewed. 2 out of 2 resident files were complete and no issues noted. LPA inspected 2 resident's centrally stored medication and records with staff. 2 out of 2 resident medications were complete and no issues noted.

LPA entered in the kitchen with the ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator and freezer observed covered and labeled.