Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Concierge and met with Executive Director (ED) Logan Harrison. LPA explained the purpose of the visit.

The facility has a fire clearance for 104 non-ambulatory; of which six may be bedridden. The facility has a hospice waiver for twenty. Currently the facility has a census of sixty-nine residents; of which one is bedridden. Currently there are seven residents on hospice.

During the visit, LPA toured the facility and observed the press button to automatically open the front doors was out-of-order. LPA reviewed paperwork submitted by the Maintenance Director for a purchase order (PO) number and the quotation was submitted and a PO number was provided. One of two elevators was also out-of-order and LPA observed the elevator was being repaired. At end of visit both elevators were operational. LPA obtained paperwork from the Maintenance Director and the fire alarms were tested by an outside vendor on 1/27/2026. The fire sprinkler system was also tested by the same vendor on 1/21/2026 and passed inspection. LPA observed fire extinguishers throughout the facility and they were charged and inspected on April 8. 2026. Evacuation chairs were observed on stairwell/stairways. The facility conducted its last fire drill on April 15, 2026 on consecutive days with different working shifts.

LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A First Aid Kit and manual are available with the required elements. The PUB 475 Poster is posted in the entryway. LPA inspected the hot water in four of four resident apartments. The hot water temperatures ranged between 112.8 to 114.1 degrees Fahrenheit.