Facility Evaluation Report

At approximately 8:45 a.m. on 06/11/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

A file review was conducted prior to the visit.

The facility was last visited on 06/02/26 for a complaint visit. It is a three (03) story building with a capacity of 176 residents. LPA observed offices, bedrooms, shared and private bathrooms, kitchen and dining areas, garage, common areas, activity rooms, garage, 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).

At 8:50 a.m., LPA inspected the facility vehicle. All systems were operational. LPA conducted a file review at 9:30 a.m. The Emergency Disaster Plan was last reviewed on 05/10/26. Liability Insurance was updated on 01/01/26. The Infection Control Plan was last updated on 12/05/25. The Dietitian/Nutritionist consultation was performed on 03/06/26. REG4 fire testing was completed on 04/03/26. All systems passed inspection. LPA reviewed at least ten (10) percent of staff and resident files. All files were complete, current, and available for audit.

LPA observed new carpets and fresh paint on hallway walls on the first floor. Interview with the maintenance director at 9:05 a.m. revealed the first floor was renovated in February 2026. Between 12:00 p.m. and 2:00 p.m. today, LPA and the administrator toured the facility. Cameras were observed near the main entrance. The designated smoking area at the front contained artificial shrubs and umbrellas for shade.