Facility Evaluation Report

At 8:45 a.m. on 07/03/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the interim Executive Director (ED) and disclosed the reason for the visit. The facility was last visited on 06/06/25 for a complaint visit. It is a two story building with eighty-three (83) private and shared bedrooms, private and shared bathrooms, kitchen, dining area, common areas, activity areas, exercise room, offices, beauty salon, theatre, laundry room, and outdoor areas. It has an approved fire clearance for ninety (90) nonambulatory residents. Approved hospice waivers for five (05).

Near the main entrance and mail room, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, facility license and sketch, theft and loss policy, personal rights, rights of resident councils, admission agreement, transportation schedule, activity schedules, and daily menus. Walls, floors, windows, screens, and blinds were clean and in good repair. Coffee, water, and snacks were available near the lobby. Surveillance cameras were observed on the exterior and in common areas. The facility has two (02) elevators. Both were in working order. Resident mailboxes were located near the main entrance near staff offices. The laundry room was locked and contained two (02) operable washers, two (02) operable dryers, and detergents. Interview with the ED around 9:10 a.m. today revealed some cameras are used by families in resident rooms with no audio. Exits are secured with keypad locks. At approximately 9:30 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. The fireplace was appropriately covered. Hand sanitizer stations are posted throughout the facility on both floors. At approximately 9:40 a.m. LPA observed fully charged fire extinguishers on the first and second floor hallways which were last inspected on 10/11/24. Flashlights were also placed in each fire extinguisher housing for emergency lighting purposes. At approximately 9:45 a.m., smoke and carbon monoxide detectors within rooms were tested and deemed operational. Emergency exits were illuminated, unlocked, and free from obstructions.