Facility Evaluation Report

Licensing Program Analysts (LPA)'s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with Administrator Ramona Eleco.

LPA's toured the facility. Facility was set at a temperature of 73F to 74 F on the 3 halls. Fire extinguisher was dated 3/8/25. Last fire drill was conducted 1/25 and 5/25. Smoke detectors are hard wired with a fire panel. Carbon monoxide detectors were properly operating. Facility has a sprinkler system that was serviced annually.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. LPA's observed a large round dining room table blocking a fire exit in the dining room. LPA's took photos. Facility has alarms on exit doors.

Resident rooms were furnished and clean. Resident bathrooms with clean with grab bars and skid mats. A sample of rooms water temperature was checked for each hall measuring between 108 F to 111 F.

A tour of the outside was conducted. There was outdoor seating with shaded tables for the residents.

LPA Doucette reviewed resident and staff records. Staff training was current. Current first aid and CPR were reviewed. LPA Hurt reviewed resident medications. LPA Hurt observed morning medications for Residents AM medications for 06/26/2025 not in bubble packs. LPA Hurt observed the medications in small pill cups taped together in a tower with residents name scribbled on each cup. LPA's reviewed Plan of Operation, and Emergency Disaster Plan (LIC610E) and facility Infection Control Plan.

A copy of this report with plans of corrections and appeal rights were provided to the Administrator via email. Civil Penalties were issued for fire clearance violation.