Facility Evaluation Report

At approximately 11:00 am. on 04/10/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit.

Today’s annual visit is a continuation of yesterday’s annual visit. Today, LPA toured the facility at 11:05 a.m., interviewed staff and residents between 11:10 a.m. and 12:30 p.m., and reviewed pertinent records including but not limited to admission agreements, medical assessments, care plans, and hospice and home health files at 12:35 p.m. Files were complete and available for audit, though two (02) home health binders were missing plans of care. The residents were recently admitted, so LPA provided a Technical Violation and consulted the licensee on maintaining complete documentation for outside agencies.

Interview with the administrator at 3:00 p.m. on 04/09/26 revealed a dietitian had not reviewed the facility’s menu and food service program within the last six (06) months. Therefore, a deficiency is cited on the corresponding LIC 809-D page.

No immediate health or safety concerns were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.