Facility Evaluation Report

At 12:45 p.m. on Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit.

During the course of investigation of complaint #31-AS-20251203164348 today and complaint #31-AS-20251117123125 on 12/02/25, LPA discovered deficiencies in the facility.

At approximately 9:40 a.m. on 12/02/25 during a facility tour, LPA observed the northern exit gate was locked with a padlock. Review of the facility sketch revealed that was an emergency exit leading to a designated assembly point. A deficiency is issued on the corresponding LIC 9099-D page for locking an emergency exit path.

At approximately 9:50 a.m., LPA observed the roof entrance above the dining room to be unlocked with no auditory alarm installed. The roof was therefore accessible to residents. No staff were supervising the area, although it was the Assisted Living portion of the facility. LPA conducted a record review at approximately 11:00 a.m. and interviewed the administrator at the same time. Record review and interview revealed at least one (01) resident in the Assisted Living side has dementia, and therefore the roof should not be accessible to residents with dementia. Deficiency is cited on the corresponding LIC 9099-D page.

Record review of the medical assessment of Resident #1 (R1) around 11:30 a.m. on 12/02/25 revealed they were bedridden. An incident report submitted on 11/30/25 confirmed R1 was “bedbound”. Review of the facility’s fire clearance revealed the facility can admit eight (08) bedridden residents in Rooms 103-108, 129, 130, 189 or 190. R1 did not reside in a room designated for bedridden residents. A deficiency is cited on the corresponding LIC 9099-D page for violating the facility’s fire clearance.