Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Krystal Boyles-Ambrecht. The annual fees are current. There are residents with a diagnosis of dementia and no residents receiving hospice services. Required postings were observed.

LPA/staff initiated a tour of the facility at approximately 11:30 am and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Facility has a pool that is surrounded by a locked gate to ensure resident safety. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Water temperature in resident's bathrooms measured at 101.3, 103.1 and 101.8 degrees F in bathrooms used by residents in care , which are not within the range allowed by regulation. Toxins were inspected and are stored in the locked laundry room. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last inspected May, 2024. Smoke alarms throughout the facility and carbon monoxide detector were tested and operational. Auditory alarms are operational. Last disaster drill conducted on 5/16/2024. Medications in a locked cabinet in the kitchen.

At approximate 11:45 am LPA/staff observed that toilet located in bathroom #2 was not properly flushing. Also, upon entering to bathroom #3 located in the hallway, LPA/staff smelled a strong odor and it was apparently due to bathroom does not have adequate ventilation.