Facility Evaluation Report

On 8/12/2025, Licensing Program Analysts LPA J. Leffall arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were greeted by receptionist, stated the purpose of the visit and met with Administrator (A1) Linda Pope. LPA conducted tour of facility with A1. Residents were observed in activity room.

The facility was observed to be at a comfortable temperature, clean, in good repair with no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 11/18/2024. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer and refrigerator. Refrigerator temperature was observed maintained at 38 degrees F. and freezer was observed maintained at -2 degrees F. All chemicals were in locked storage. LPA toured a sample of resident bedrooms, activity room, dining room and enclosed patio area. Residents' rooms were toured and observed with adequately furnished bed, dresser, and adequate lighting. LPA observed securely fastened grab bars next to toilet and all tub/shower areas. 5 out of 5 residents rooms observed with non-skid shower strips. 5 out of 5 residents bathroom temperatures measured at a range of 106.7 to 107.2 degrees F.

LPA completed a medication audit. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. Centrally Stored Medication Record observed. Samples of staff files were reviewed to have the required documents. Samples of resident’s files were reviewed to have all the required documents.

No deficiencies issued during today's inspection.

An exit interview was conducted with Licensee. A copy of this report was discussed and provided to Administrator whose signature on this form confirms receipt of this document.