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25 | At 8:00am on 03/13/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct the annual facility inspection. LPA met with Administrator Dorothy Berger, announced who he is and the reason for the visit.
This facility has a fire clearance for a secured perimeter and has 12 resident room. 10 rooms are single resident occupancy, and rooms #3 and #12 are double resident occupancy. All resident rooms are properly furnished with bedding, storage, seating and lighting according to regulations There is one on suite bathroom for room #12 and there are 4 bathrooms that are located through out the facility that are community use bathrooms. All bathrooms have liquid soap and paper towels. LPA noted non-skid mats showers. There is a large great room that serves as a dining room, living room and activities room. LPA noted that there is a kitchen on the north side of the facility, however this facility's food service is maintained by the same owners and administrators adjacent licensed facilities kitchen. The main food supply is located at the adjacent facility where LPA noted at least a 2 day supply of non perishable foods and at least a 7 day supply of perishable foods on hand for 28 (both facilities have a maximum number of 14 residents per facility) residents and staff. LPA noted that the facility has a medication room in the hallway near resident room #12. LPA noted that the first aide kit is located in the medication room. LPA noted the facility has overhead sprinkler system with smoke detection that was last tested and certified by Alpha Fire on 10/24/2024. LPA noted wire carbon monoxide detector with a green light throughout the facility. LPA noted three fire extinguishers throughout the facility that were charged in the green and currently tagged as serviced. LPA noted that all passage ways were free and clear of debit and obstacles. LPA noted that the fire clearance authorized locked gates on the perimeter gates. LPA conducted a sample review of staff and resident files. LPA noted that all staff are current on training with 1st Aide and CPR training up to date. LPA conducted a sample medication audit and did not discover any deficiencies. LPA noted and reviewed facilities current emergency disaster plan and infection control plan, LPA conducted a full review of the annual care tools and found no citations or deficiencies. This annual inspection did not revel any citations or deficiencies.
Exit interview, report read, and report provided. |