Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Melissa Genet: Administrator Certificate 7021074740 expires 12/1/25. Facility contact information was reviewed.

At approximately 11:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Hall closet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. LPA observed prescription milk of magnesia on an open shelf in the kitchen along with thickener. LPA discussed with Admin keeping all medication, including over the counter items and nutritional supplements in the medication closet as it must remain inaccessible to residents. Admin immediately removed items from shelf and secured them in the medication cabinet.

The main bathroom across from the living room has a little closet that houses the sprinkler equipment. The door to the closet is splintering and cracking at the bottom posing a safety hazard to residents. The main bath next room #9 had a leak under the sink. The leak has been fixed but the wood/plywood/sheathing on the bottom/base of the vanity cabinet has a black substance present with spots and dots of a white fuzzy substance ( deficiencies cited, see 809D )

All bedrooms were equipped with lighting, night stand, and chest of drawers, except for resident (R2) . R2 did not have a lamp. Admin says they broke it and family doesn't want another one in there. LPA advised get a note from the family and put it in the resident's file. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 108.6 degrees F which is within the allowable range of 105 to 120 degrees F.