Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Admin not present at facility but available via telephone. Admin arrived later.

At approximately 9:15am LPA and caregiver 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. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. 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 110 and 108.1 degrees F which is within the allowable range of 105 to 120 degrees F.

LPA and caregiver observed resident (R1) to have strong smell of urine on her person. LPA verified that urine smell is not from urine soaked bed or furniture. LPA discussed with Admin and caregiver that resident must be kept free of incontinence odor and be kept clean and dry. Resident is currently on hospice and has pressure wound/ulcer which makes incontinence care even more crucial. Caregiver will now document every time resident refuses a shower and every time a sponge bath is given.

Fire extinguishers were last inspected 5/17/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 8/10/2024 Facility has a backup generator for use during a power outage.