Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Plan of Correction (POC) visit. LPA was greeted and granted entry by Lorna Smith, Administrator (AD) at 2:30pm and explained the purpose of the visit.

AD and LPA walked the facility and AD pressed the fire/ carbon monoxide alarm; which is electrical and is interconnected with other alarms throughout the home. LPA observed detectors to be operational throughout the residence and cleared this deficiency with the POC visit. AD also provided video documentation to LPA on Friday, May 9, 2025 showing the alarms were working at time of LPA's annual required visit but that the button had not been pressed long enough to activate the auditory alarms. The appeal process was discussed with AD.

LPA toured four of four bedrooms and all bedrooms have beds, mattresses, linens, lamps and dressers. LPA has cleared this deficiency with the POC visit. AD has requested an extension until Wednesday, May 14, 2025 to obtain a medical assessment for one of one residents.

Based on LPA observations, two of three deficiencies were cleared during this visit. An exit interview was conducted with AD Lorna Smith and a copy of this report was provided to the facility.