Facility Evaluation Report

At approximately 10:30 a.m. on 04/30/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and Vice President of Operations (VP) and disclosed the reason for the visit. The Regional Director of Operations later joined the visit at approximately 1:00 p.m. Due to time constraints, LPA returned to the facility today at approximately 9:30 a.m. and finished the inspection with the administrator and VP.

A file review was conducted prior to the visit.

The facility was last visited on 03/18/25 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPA observed bedrooms, shared and private bathrooms, kitchen and dining areas, garage, common areas, activity rooms, offices, and a courtyard. It has an approved fire clearance for 176 nonambulatory residents, of which fifty (50) may be bedridden. Approved hospice waivers for thirty (30).

Between 10:30 a.m. and 3:30 p.m. on 04/30/25 and between 9:30 a.m. and 11:00 a.m. today, LPA, administrator, and VP toured the facility. At approximately 10:00 a.m. on 04/30/25 the facility telephone was called and deemed operational. At 1:30 p.m. on 04/30/25, a medication review was conducted for nine (09) residents. All medications quantities were maintained and documented in the correct amounts. At 3:30 p.m. on 04/30/25, LPA conducted a file review for resident and personnel records. All files were complete and available for audit. LPA also reviewed the most recent fire safety inspection from 11/26/24 in which all systems passed. The most recent fire safety drill was conducted on 04/26/25. Liability insurance and surety bond were both current.