Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unnanounced to conduct a Required Annual Inspection and met with Toni Pump, Administrator. There is currently one resident receiving hospice services and residents with a diagnosis of dementia. Annual fees are current.

LPA/Administrator toured the facility inside, outside and made the following observations: Facility was a comfortable temperature with thermostat reading at 70 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 113.7, 113.5 and 112.9 which are within allowable range of 105 to 120 degrees F in faucets used by residents. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cleaning supplies were not accessible to residents in care. Knives are located in a locked closet in the kitchen. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected May 2024. Smoke and Carbon Monoxide detectors were tested during inspection and operational. Exit doors have auditory alert system that were functional at time of visit. The facility have not conducted a disaster drill within the last quarter (technical violation was issued). Medications and medication records were reviewed. Required postings observed.

LPA initiated file review at 10:00 am. Five resident and three staff files were reviewed. One out of five residents needs appraisals/needs and services plans to be updated (technical violation issued). Staff have required First aid and CPR certificates and required additional training hours completed per regulation. Continue on LIC809C...